Effective April 23, 2020
Suspension of Prior Authorizations or Continued Stay Reviews and Clinical Requirements for Some Medicaid Programs
Montana Healthcare Programs is continually working to improve safe access to Medicaid services throughout the public health emergency. This provider notice is to suspend the prior authorization or continued stay reviews and clinical requirements for some Medicaid programs during the statewide emergency declared in Executive Orders 2-2020 and 3-2020.
This provider notice will remain in effect through the remainder of the COVID-19 epidemic. Future provider notices will specify individual program resumption dates and specific steps to follow for resuming prior authorization, continued stay and clinical requirements.
For most Montana Medicaid programs, prior authorization and continued stay reviews are lifted for the duration of the epidemic but clinical criteria in rule will remain in place. It is the responsibility of the provider to document the clinical criteria. The following exceptions apply:
1. Prior authorization and continued stay reviews are still required for the following programs:
Addictive and Mental Disorders Division
- Inpatient Hospital (Montana State Hospital) (under 18 and over 64 years of age)
- Medically Monitored Intensive Inpatient Substance Use Disorder (SUD) Treatment (ASAM 3.7)
- Substance Use Disorder Intensive Outpatient Services (IOP) (ASAM 2.1)
Developmental Services Division/Children’s Mental Health Bureau
- Children’s Mental Health Bureau Early Periodic Screening, Diagnostic, and Treatment (EPSDT)Reviews
- Intermediate Care Facility – Individual with Intellectual Disability (ICF-IID)(out-of-state)
- Psychiatric Residential Treatment Facility (in-state, out-of-state, and assessment)
- Youth Mental Health Genetic Testing
Health Resources Division
- Audiology and Hearing Aid Services
- DME items reimbursed over $5,000 (formally $1,000 as found on Prior Authorization Chapter ofthe DME Manual
- Early, Periodic Screening, Diagnostic, and Treatment (EPSDT) Reviews
- Eyeglasses and Contact Lenses
- Home Infusion Therapy
- Interim Hospital Claims
- Personal and Non-Emergency Medical Transportation
- Physician Administered Drugs
- Orthodontia
- Outpatient Pharmacy
For out-of-state hospitals with patients admitted prior to April 23, 2020 continued stay reviews are still required until discharge.
2. Montana Medicaid has temporarily lifted clinical criteria in addition to prior authorization and continued stay reviews requirements for the following Medicaid programs to allow for flexibility in intake and discharge that may be required as a result of the COVID-19 epidemic:
Addictive and Mental Disorders Division
- Adult Group Home (AGH)
- Clinically Managed Low-Intensity Residential SUD Treatment (ASAM 3.1)
- Crisis Stabilization Program (Crisis Intervention Facility)
Developmental Services Division/Children’s Mental Health Bureau
- Partial Hospital Services
Claim Submission Instructions
Many Medicaid services allow providers to span bill for multiple days. In order to avoid denied claims for services that are span billed, providers will need to submit separate claims as follows:
- For services up to and including April 22, 2020, providers will be required to submit claims with the prior authorization number as normal.
- For those services identified in this provider notice as NOT needing a prior authorization, a separate claim will need to be submitted for services starting April 23, 2020.
