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Long Term Care Services – Requests for home health services to include skilled nursing, physical therapy, occupational therapy, speech therapy and home health aide are reviewed to determine medical necessity and ascertain the service is skilled. Home health skilled services are typically provided to individuals age 21 and older. The initial request for service must be received at Mountain-Pacific within five business days of the start of home health services by the agency. The nurse allocates a specific number of visits for the home health service requested. Request for continuation of home health services for a client, beyond the initial number of authorized visits, must be received prior to implementing any additional visits.
Skilled nursing services for individuals age 20 and younger are most often provided through Private Duty Nursing/EPSDT. Skilled physical therapy, occupational therapy and speech therapy are not available through PDN/EPSDT for this age group and therefore these services are authorized through home health. PDN/EPSDT requests must be received prior to the start of services. A date span with a specific number of units/visits is authorized by the nurse reviewer. Request for continuation of PDN/EPSDT services beyond the initial number of authorized units must be received prior to implementing any additional units.
Procedures – Providers submit notification of the need for these services by fax or phone. Documentation to support medical necessity and a physician’s order must be faxed with the designated PDN form to Mountain-Pacific. Mountain-Pacific’s nurse reviewers process these requests within one business day of receipt.
For Home Health review, Mountain-Pacific staff can be reached at 800-219-7035 or by fax at 800-413-3890.
For Private Duty Nursing/EPSDT review, Mountain-Pacific staff can be reached at 800-262-1545 or by fax at 800-497-8235
Process – Mountain-Pacific nurse reviewers assess the request to assure it meets the requirements of the Administrative Rules of Montana and/or the provider manuals. In addition the nurse determines that the service is medically necessary and that the service requested is skilled as defined by the State Board of Nursing.
Determination– If a service is authorized, Mountain-Pacific will notify the provider by fax, and generate a prior authorization number. When the service is denied a denial letter with appeal rights will be mailed to the provider and the client notifying them of the reason for the denial.
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