Medicaid Utilization Management
Under contract with the Montana Department of Public Health and Human Services (DPHHS), Mountain-Pacific Quality Health 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.
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.
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:
Provider User Guide for Montana Medical Services Processed through Qualitrac
Provider User Guide for Montana Behavioral Health Services Processed through Qualitrac
Mountain-Pacific Quality Health, in partnership with Telligen, provides the utilization management and review of the following behavioral health services covered through Montana Healthcare Programs provided by Montana DPHHS:
- Clinically managed low-intensity residential (ASAM 3.1)
- Clinically managed high-intensity and medium-intensity residential (ASAM 3.5)
- Medically monitored high-intensity inpatient (ASAM 3.7)
- Crisis stabilization program
- Psychiatric residential treatment (in and out of state)
- Acute inpatient hospital services (out of state)
- Therapeutic group home (youth)
- Therapeutic home visit (youth)
- Extraordinary needs aide services
- Genetic testing (youth with behavioral health diagnosis)
- Intensive outpatient program
- Program assertive community treatment
- Intensive community-based rehabilitation
- Adult group home
- Partial hospitalization (youth)
- Home support services
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
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
- necessary to treat the person’s primary or co-existing conditions;
- offered in Montana.
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.
Database of Specialty Services
Physicians listed in this database of specialty services offered in Montana 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.
We also review and track all transplant services. All transplant services, except corneal transplants, must be authorized before the procedure.
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
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
- physician orders and progress notes,
- operative reports,
- test or study results,
- other clinical information.
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
Mountain-Pacific Quality Health administers a prior authorization program for several physician-administered drugs (PAD) for Montana Healthcare Programs. Our clinical pharmacy team reviews a provider’s request for these complicated, often expensive treatments. Provider requests are submitted through our provider portal 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.
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
- wheelchairs,
- hospital beds,
- oxygen equipment,
- monitors,
- orthotics.
Mountain-Pacific determines if DME that costs more than $1,000 or is designated for review is medically necessary and the least costly option.
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
Mountain-Pacific Quality Health helps Montanans with Medicaid avoid unnecessary institutionalization or hospitalization. We work with local agencies to review each Medicaid client’s plan of care to authorize skilled home health services. We make sure home health services are
- medically necessary;
- skilled in nature like nursing, physical therapy, occupational therapy and speech therapy;
- can be appropriately provided at the person’s home.
Our registered nurses authorize a specific number of home visits and review any additional requests for ongoing services, as needed.
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
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’s 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’s condition changes.
Provider Education and Training
Training resources are posted in our Medicaid provider portal under Education & Training.
The Medicaid program’s 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.
Level of Care Reviews for Long-Term Care Services
Many 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.
Provider Education and Training: Medicaid Waiver Process Webinar (August 2, 2018)
Level of Impairment (LOI) Reviews for Severe Disabling Mental Illness (SDMI) Services
LOI 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.
Preadmission Screening and Resident Review
To 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.
Nursing Facility Level of Care and Continued Stay Reviews
Mountain-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.
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.
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:
- Bathing
- Going to the bathroom
- Moving around the house
- Eating
- Meal planning and preparation
- Personal hygiene and grooming
- Exercise
- Doing laundry
- Shopping for food or medical supplies
- Getting to medical appointments
Through Community First Choice, people at risk of institutionalization can also receive these services as part of an individualized, person-centered care plan.
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’s 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.