Montana MT

Montana Medicaid uses Primary Care Case Management (PCCM) — branded "Passport to Health" — where most beneficiaries are assigned to a primary care provider who coordinates their care. PCCM is distinct from MCO managed care: there is no capitated risk contract; the PCP is paid a small care-management fee on top of FFS reimbursement.

Montana Medicaid is administered directly by the Montana Department of Public Health and Human Services (DPHHS). Traditional fee-for-service delivery system — no comprehensive MCOs. State pays providers directly. Confirms FFS shape classification.

Montana Medicaid (DPHHS) is FFS-dominant (Passport to Health / new Primary Care Montana PCMT — PCCM, no risk MCO). PA is published as ONE canonical DPHHS page (medicaidprovider.mt.gov/priorauthorization): a single accordion listing ~24 services/procedures, with the actual clinical CRITERIA written INLINE as text per service (Artificial Disc Replacement, Blepharoplasty, BRCA testing, Breast Reconstruction, DME, Reduction Mammoplasty, Rhinoplasty, TMJ, Panniculectomy, etc.). A few criteria are standalone PDFs in /docs/priorauth/ (Panniculectomy, Breast Reconstruction) and PA forms in /docs/forms/. Service-detail PA rules also live in per-service provider manuals (General Information for Providers Manual + program manuals). UM/review vendor = Mountain-Pacific Quality Health (MPQH); medical/PAD/level-of-care PA submitted via the Qualitrac portal (mpqhf.org medicaid-portal). Pharmacy outpatient PA = state PDL (medicaidprovider.mt.gov PDL PDF) + MPQHF pharmacy criteria. Physician-administered-drug criteria are posted on MPQHF (a few example PDFs on the MT site, e.g. Aduhelm). Portals: MATH/Conduent (mtaccesstohealth.portal.conduent.com) + Optum MPATH (mtdphhs-provider.optum.com) for claims; MPQH Qualitrac for clinical PA. NOT a WISeR state. This differs from CA tri-locus and WA process — MT is a single state-published inline-criteria page backed by one UM vendor.

Last award: 2024-07-10 (Conduent PBM renewal). Next due: ~2027-07 (Conduent 3-year term expiry, approximate). Contracts extended through: unknown precise date; renewal announced July 2024 covers 3 years.

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# MT — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 11 docs. See [[state_shape_MT]]. Correction pass: WISeR is not applicable to MT — WISeR ("Wasteful and Inappropriate Service Reduction") is a CMS Medicare PA model limited to AZ/NJ/OH/OK/TX/WA; MT does not participate. The model's "WISeR pilot status unspecified" line was a template artifact, corrected below. ## 1. How MT requires PA Montana Medicaid (administered by the Montana Department of Public Health and Human Services - DPHHS) requires prior authorization (PA) for a variety of services and procedures to ensure medical necessity and appropriate utilization. The specific criteria for each service are detailed on the DPHHS website under the "Prior Authorization" section. For example, services like panniculectomy, breast reconstruction, orthognathic surgery, and genetic testing for BRCA-related cancer all have distinct clinical criteria that must be met before authorization is granted. The PA process varies by service type: - **Panniculectomy**: Requires documentation of medical necessity, conservative treatments, pre-operative photos, height, weight, and stabilized weight. The panniculus must be Grade II or more, with recurrent infections/ulcers not responding to treatment for 3 months, or significant weight loss (50% of excess weight). - **Breast Reconstruction**: Not covered if reconstructive; revisions are only considered medically necessary in cases of infection, grade III+ painful contracture, or medically necessary implant rupture (saline-filled only if originally medically necessary). - **Orthognathic Surgery**: Requires anteroposterior, vertical, and transverse discrepancies (≥2 SD from norms), asymmetries >3mm with occlusal asymmetry, masticatory dysfunction, and limitations of non-surgical therapies. Documentation must include a DPHHS approved orthodontic treatment plan, images, and coordination between the surgeon and orthodontist. - **Genetic Testing for BRCA-Related Cancer**: Criteria include age over 18 with personal or family history meeting specified conditions. For drugs, certain long-acting opioids like Butrans Patch and morphine sulfate SR tab require clinical criteria for prior authorization. The process involves contacting Mountain Pacific Quality Health (MPQH) Clinical Call Center for details. ## 2. How MT publishes and reports PA Montana Medicaid publishes its PA requirements on the DPHHS website, specifically under the "Prior Authorization" section at medicaidprovider.mt.gov/priorauthorization. This page contains an accordion listing approximately 24 services/procedures with inline clinical criteria. The provider manual, at medicaidprovider.mt.gov/manuals/generalinformationforprovidersmanual, governs drugs and services requiring PA. It specifies the need for medical necessity documentation, step-therapy requirements, and other necessary documentation. Specific CPT codes are generally not detailed in this document. For certain procedures like orthodontia, a separate form is required for submission, detailing the necessary documentation and criteria. Effective dates are often specified within each document. ## 3. MT's CMS-0057-F and PA-reform compliance posture Montana Medicaid has a partial centralized PA portal — an online component exists but is not fully integrated across all services; the state relies on various forms and documents on the DPHHS website. Regarding CMS-0057-F compliance, Montana's posture is unclear from the source documents. The state uses MPQH/Qualitrac for utilization management (UM), suggesting some standardization in PA criteria and documentation. (WISeR not applicable — MT is not one of the six WISeR-model states.) ## 4. How MT runs its own program Montana Medicaid is administered directly by the DPHHS under a fee-for-service (FFS) model, without comprehensive managed care organizations (MCOs). The state pays providers directly. This FFS system includes Primary Care Case Management (PCCM), branded as "Passport to Health," where primary care providers coordinate care for most beneficiaries. The state has several 1115 waivers, including HELP (Medicaid Expansion), HEART (Healing and Ending Addiction through Recovery and Treatment), WASP (Waiver for Additional Services and Populations), and Plan First. The fiscal agent history shows transitions from ACS-Inc to Conduent/Gainwell. Per source documents, the most recent Conduent PBM contract renewal was announced July 10, 2024, covering a three-year term. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Direct FFS Model**: Montana Medicaid operates under a direct fee-for-service model without comprehensive MCOs. - **Primary Care Case Management (PCCM)**: The state uses PCCM to coordinate care, distinct from capitated risk contracts. - **Specific PA Criteria**: Detailed clinical criteria are provided for various services, indicating a strong emphasis on medical necessity. ### What's Missing/Uncertain: - **CMS-0057-F Compliance**: Unclear due to the partial centralized portal and reliance on multiple documents. - **Effective Dates**: Some PA criteria documents do not specify effective dates. - **CPT Codes**: Often not detailed in broader documentation like the provider manual. - **WISeR**: Not applicable — MT is not a WISeR-model state. - **Foster Care Program Details**: Unspecified in the sources.