Under contract with the Montana Department of Public Health and Human Services (DPHHS), Mountain Pacific provides utilization management and review services for Montana Healthcare Programs in accordance with federal and state rules and regulations and related state policies and procedures.<\/p>\n
Together, our goal is to make sure each Medicaid member in Montana gets what he or she needs in the most appropriate, cost-effective way.<\/p>\n
Mountain Pacific has developed the following user guides that provide a quick reference to important information about required information and associated time lines as well as demonstrating the fields providers will encounter in the Qualitrac portal: <\/p>\n Mountain Pacific, in partnership with Telligen<\/a>, provides the utilization management and review of the following behavioral health services covered through Montana Healthcare Programs<\/a> provided by Montana DPHHS:<\/p>\n Provider Education and Training<\/strong> When a Medicaid member wants to go or is referred to go to a hospital outside of Montana for inpatient or rehabilitation services, Mountain Pacific reviews that request. We determine whether the services are<\/p>\n If the service is available in Montana, the request may not be approved. A hospital within 100 miles of the Montana border is not considered out-of-state.<\/p>\n Database of Specialty Services<\/strong> We also review and track all transplant services. All transplant services, except corneal transplants, must be authorized before the procedure.<\/p>\n Provider Education and Training<\/strong> For certain physician-related medical services and surgical procedures, Mountain Pacific reviews appropriate medical records to determine whether these services are covered by Medicaid, medically necessary and cost-effective. To do this, clinical staff may review<\/p>\n Provider Education and Training<\/strong> Mountain Pacific administers a prior authorization program for several physician-administered drugs (PAD) for Montana Healthcare Programs<\/a>. Our clinical pharmacy team reviews a provider\u2019s request for these complicated, often expensive treatments. Provider requests are submitted through our provider portal<\/a> and routed to our pharmacy experts who review the claim to make sure it satisfies state drug utilization board requirements. Via the portal, providers can access the claim in real-time to track its progress. They also receive an email notification when a decision is made. This process ensures streamlined communication and reduces the burden on providers and their staff.<\/p>\n<\/div><\/div>\n DME is equipment used at home for medical purposes by people with an illness or injury. The equipment must be able to withstand repeated use. Examples of DME include<\/p>\n Mountain Pacific determines if DME that costs more than $1,000 or is designated for review is medically necessary and the least costly option.<\/p>\n Provider Education and Training<\/strong> Mountain Pacific helps Montanans with Medicaid avoid unnecessary institutionalization or hospitalization. We work with local agencies to review each Medicaid client\u2019s plan of care to authorize skilled home health services. We make sure home health services are<\/p>\n Our registered nurses authorize a specific number of home visits and review any additional requests for ongoing services, as needed.<\/p>\n Provider Education and Training<\/strong> Skilled nursing services for Medicaid members under the age of 21 are usually provided through private duty nursing. This program helps prevent or identify and treat children\u2019s health problems. Mountain Pacific works with school staff and families to help provide necessary private duty skilled nursing services. These services are pre-authorized and reassessed any time the child\u2019s condition changes.<\/p>\n Provider Education and Training<\/strong> The Medicaid program\u2019s benefit for children and adolescents is known as Early and Periodic Screening, Diagnostic and Treatment services, or EPSDT. EPSDT provides a comprehensive array of prevention, diagnostic and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to make sure children receive early detection and care, so health issues are averted or diagnosed and treated as early as possible.<\/p>\n<\/div><\/div>\n Level of Care Reviews for Long-Term Care Services<\/strong> Provider Education and Training: Medicaid Waiver Process Webinar (August 2, 2018)<\/a><\/p>\n Level of Impairment (LOI) Reviews for Severe Disabling Mental Illness (SDMI) Services<\/strong> Preadmission Screening and Resident Review<\/strong> Nursing Facility Level of Care and Continued Stay Reviews<\/strong> Our team of nurses completes federally required periodic reviews to determine the need for Medicaid members’ continued stay in a nursing facility, either in a skilled or non-skilled setting.<\/p>\n<\/div><\/div>\n Personal assistance services, or PAS, are provided to people with full Medicaid coverage who need help with day-to-day activities at home, for example:<\/p>\n Through Community First Choice, people at risk of institutionalization can also receive these services as part of an individualized, person-centered care plan.<\/p>\n Our registered nurses visit people eligible for these services at their homes. Social workers also assist by interviewing these applicants. Together, we determine the level of care an individual needs. If an applicant\u2019s needs meet program guidelines, Mountain Pacific staff complete an authorization form. The form includes how often the person needs care. The form then goes to a provider agency selected by the applicant or a representative.<\/p>\n<\/div><\/div>\n <\/p>\n Medicaid Utilization Management Clinically managed low-intensity residential (ASAM 3.1) Provider Education and Training Out-of-State Inpatient Medical Admissions necessary to treat the person’s primary or co-existing conditions; If the service is available in Montana, the request may not be approved. A hospital within 100 miles of the Montana border is not considered out-of-state. Physician Services physician orders and progress notes, Provider Education and Training Physician-Administered Drugs (PAD) Durable Medical Equipment (DME) wheelchairs, Mountain Pacific determines if DME that costs more than $1,000 or is designated for review is medically necessary and the least costly option. Home Health medically necessary; Our registered nurses authorize a specific number of home visits and review any additional requests for ongoing services, as needed. Private Duty Nursing Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services
\nProvider User Guide for Montana Medical Services Processed through Qualitrac<\/a>
\nProvider User Guide for Montana Behavioral Health Services Processed through Qualitrac<\/a><\/p>\n\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n\n
\nPhysicians listed in this database of specialty services offered in Montana<\/a> are either board-certified or have fellowships in adult and pediatric care. This database provides the hospitals and phone numbers for ease of access to these in-state specialty services.<\/p>\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n<\/div><\/div>\n
\nMany people who need long-term care (LTC) services can get that care in their homes and communities. This kind of care often costs less than care received at a hospital or nursing facility. Montana DPHHS contracts with Mountain-Pacific Quality Health to help Montanans with Medicaid stay in their homes.<\/p>\n
\nLOI assessments are used to identify areas in which a member’s mental health impacts their ability to function and area(s) that requires home and community-based services and support. Montana DPHHS contracts with Mountain Pacific to complete these assessments by licensed clinical social workers or licensed clinical professional counselors.<\/p>\n
\nTo make sure people are not inappropriately placed in nursing homes for long-term care, Mountain Pacific reviews cases for any signs of mental illness or intellectual disability. If we identify any mental illness or intellectual indicators, we offer referrals for specialists who can help these clients.<\/p>\n
\nMountain Pacific contracts with Montana DPHHS to determine whether someone meets level-of-care criteria to be admitted to a long-term care facility (nursing home). Once the individual is admitted, continued stay reviews are completed to determine whether the member continues to meet criteria to reside there.<\/p>\n\n
This project is funded in whole or in part under a Contract with the Montana Department of Public Health and Human Services. The statements herein do not necessarily reflect the opinion of the Department.<\/em><\/h6>\n","protected":false},"excerpt":{"rendered":"
\nUnder contract with the Montana Department of Public Health and Human Services (DPHHS), Mountain Pacific provides utilization management and review services for Montana Healthcare Programs in accordance with federal and state rules and regulations and related state policies and procedures.
\nTogether, our goal is to make sure each Medicaid member in Montana gets what he or she needs in the most appropriate, cost-effective way.
\nMountain Pacific has developed the following user guides that provide a quick reference to important information about required information and associated time lines as well as demonstrating the fields providers will encounter in the Qualitrac portal:
\nProvider User Guide for Montana Medical Services Processed through Qualitrac<\/a>
\nProvider User Guide for Montana Behavioral Health Services Processed through Qualitrac<\/a>
\nIf you have questions about these services after reviewing the below information, please call us toll-free at 1-800-219-7035.
\n
\nMental and Behavioral Health Services
\nMountain Pacific, in partnership with Telligen<\/a>, provides the utilization management and review of the following behavioral health services covered through Montana Healthcare Programs<\/a> provided by Montana DPHHS:<\/p>\n
\nClinically managed high-intensity and medium-intensity residential (ASAM 3.5)
\nMedically monitored high-intensity inpatient (ASAM 3.7)
\nCrisis stabilization program
\nPsychiatric residential treatment (in and out of state)
\nAcute inpatient hospital services (out of state)
\nTherapeutic group home (youth)
\nTherapeutic home visit (youth)
\nExtraordinary needs aide services
\nGenetic testing (youth with behavioral health diagnosis)
\nIntensive outpatient program
\nProgram assertive community treatment
\nIntensive community-based rehabilitation
\nAdult group home
\nPartial hospitalization (youth)
\nHome support services<\/p>\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nWhen a Medicaid member wants to go or is referred to go to a hospital outside of Montana for inpatient or rehabilitation services, Mountain Pacific reviews that request. We determine whether the services are<\/p>\n
\noffered in Montana.<\/p>\n
\nDatabase of Specialty Services
\nPhysicians listed in this database of specialty services offered in Montana<\/a> are either board-certified or have fellowships in adult and pediatric care. This database provides the hospitals and phone numbers for ease of access to these in-state specialty services.
\nWe also review and track all transplant services. All transplant services, except corneal transplants, must be authorized before the procedure.
\nProvider Education and Training
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nFor certain physician-related medical services and surgical procedures, Mountain Pacific reviews appropriate medical records to determine whether these services are covered by Medicaid, medically necessary and cost-effective. To do this, clinical staff may review<\/p>\n
\noperative reports,
\ntest or study results,
\nother clinical information.<\/p>\n
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nMountain Pacific administers a prior authorization program for several physician-administered drugs (PAD) for Montana Healthcare Programs<\/a>. Our clinical pharmacy team reviews a provider\u2019s request for these complicated, often expensive treatments. Provider requests are submitted through our provider portal<\/a> and routed to our pharmacy experts who review the claim to make sure it satisfies state drug utilization board requirements. Via the portal, providers can access the claim in real-time to track its progress. They also receive an email notification when a decision is made. This process ensures streamlined communication and reduces the burden on providers and their staff.<\/p>\n
\nDME is equipment used at home for medical purposes by people with an illness or injury. The equipment must be able to withstand repeated use. Examples of DME include<\/p>\n
\nhospital beds,
\noxygen equipment,
\nmonitors,
\northotics.<\/p>\n
\nProvider Education and Training
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nMountain Pacific helps Montanans with Medicaid avoid unnecessary institutionalization or hospitalization. We work with local agencies to review each Medicaid client\u2019s plan of care to authorize skilled home health services. We make sure home health services are<\/p>\n
\nskilled in nature like nursing, physical therapy, occupational therapy and speech therapy;
\ncan be appropriately provided at the person\u2019s home.<\/p>\n
\nProvider Education and Training
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nSkilled nursing services for Medicaid members under the age of 21 are usually provided through private duty nursing. This program helps prevent or identify and treat children\u2019s health problems. Mountain Pacific works with school staff and families to help provide necessary private duty skilled nursing services. These services are pre-authorized and reassessed any time the child\u2019s condition changes.
\nProvider Education and Training
\nTraining resources are posted in our Medicaid provider portal<\/a> under Education & Training<\/a>.<\/p>\n
\nThe Medicaid program\u2019s benefit for children and adolescents is known as Early and Periodic Screening, Diagnostic and Treatment services, or EPSDT. EPSDT provides a comprehensive array of prevention, diagnostic and treatment services for low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit is more robust than the Medicaid benefit for adults and is designed to make sure children receive early detection and care, so health issues are averted or diagnosed and treated as early as possible.<\/p>\n