How to Fill Out and Submit a Montana Medicaid Prior Authorization Form

A Montana Medicaid prior authorization form is the request a provider sends to the Department of Public Health and Human Services (DPHHS) or its review contractor, Mountain-Pacific Quality Health, to get approval for a covered service before it’s delivered. The form you use depends on the service, and using the wrong one, leaving fields blank, or omitting clinical documentation is the fastest way to have a request returned without review.¹

Pick the Right Form for the Service

Montana Medicaid uses several prior authorization forms, each tied to a category of service. All of them can be downloaded from the Montana Medicaid provider forms page.²

General Use Prior Authorization Form: most medical and surgical services that don’t have a dedicated form.
DMEPOS Prior Authorization Request Form: durable medical equipment, prosthetics, orthotics, and supplies.
EPSDT Prior Authorization and Certificate of Medical Necessity Form: Early and Periodic Screening, Diagnostic, and Treatment services for children.
Orthodontia Prior Authorization Request Form: orthodontic treatment.
Drug Prior Authorization Request Form: prescription medications that are non-preferred on the Preferred Drug List or subject to clinical criteria.

Check the version date printed on any form before you fill it in. The EPSDT form was updated in March 2025, while the General Use form dates to January 2008. An outdated form can be returned without review because it lacks required fields or references superseded policies.

One boundary worth naming: a Passport to Health referral is not the same thing as prior authorization. A Passport referral is permission from the member’s primary care provider to see another provider; prior authorization is state-level approval that a specific service is medically necessary. Some services need both, and each carries its own reference number that goes in its own field on the claim form.³

Gather Everything Before You Start

An incomplete submission doesn’t start the review clock. Have all of this in hand before you open the form:

The member’s Client ID number, exactly as it appears on the Medicaid card. The form labels this field “Client ID #.”
The member’s full legal name and date of birth, matching the card.
The billing or rendering provider’s name and National Provider Identifier (NPI).
ICD-10 diagnosis codes supporting the request.
CPT or HCPCS procedure codes identifying the exact service or item.
Clinical documentation: office notes, lab results, imaging, or specialist evaluations that show why the service is needed.

Durable medical equipment requests carry more paperwork. Along with the DMEPOS form, include a prescription from the ordering provider, a certificate of medical need where required, a narrative from the prescribing authority explaining the need, and the manufacturer’s retail price sheet with product warranty information. If a licensed therapist is treating the member, attach the plan of care related to the item, with video documentation if possible.¹

Filling Out the General Use Form

The General Use form is a single page with a grid layout. At the top, indicate whether the submission is a new request or a change to an existing authorization. If it’s a change, enter the existing authorization number in the PA# field.

The header has four fields. Client Name and Client ID # must match the Medicaid card exactly. Provider Name identifies the requesting clinician or facility. Billing or Rendering Provider identifies who will actually bill for or perform the service.

Below the header is a line-item table. Each row is one service or item being requested. The columns:

Line No.: sequential numbering starting at 1.
From Date / To Date: the date range the service will be provided.
T.O.S. Code: the Type of Service code for the category of care.
Proc. Code (or Range): the CPT or HCPCS code, or a range if requesting related codes together.
Mod (or Range): any applicable modifier codes.
Diag Code: the ICD-10 diagnosis code that supports this line item.
Tooth No/Srf: only for dental services; otherwise blank.
Maximum Units: the total units requested for this service.
Maximum Dollars: the dollar ceiling for the line item.
RSN Code: the reason code explaining why authorization is being requested.

The form itself has no free-text clinical justification area. The narrative belongs in your attached documentation. Treat the form as a structured billing summary and let the clinical case live in the records you attach, and make sure those records tie each diagnosis code on the form to the evidence supporting the requested procedure.

Pharmacy Requests Use a Separate Process

Whether a prescription needs prior authorization depends on its placement on the Montana Healthcare Programs Preferred Drug List. The PDL sorts medications as preferred or non-preferred within each therapeutic class. Drugs marked with a percent sign (%) carry clinical criteria that apply regardless of preferred status.⁴ The current PDL was revised in January 2026.

To prescribe a non-preferred drug or a medication with clinical criteria, submit the Drug Prior Authorization Request Form to Mountain-Pacific Quality Health’s Drug Prior Authorization Unit. The form asks for member information, prescribing provider details, the medication name, strength, dosage, quantity, and the clinical rationale for why this specific drug is appropriate when preferred alternatives exist.

Drug requests go to a different address and fax than general medical requests:

Phone: (800) 395-7961 or (406) 443-6002
Fax: (800) 294-1350 or (406) 513-1928
Mail: Drug Prior Authorization Unit, Mountain-Pacific Quality Health, 3404 Cooney Drive, Helena, MT 59602

One thing worth flagging: if a member previously received a medication through manufacturer samples, patient assistance programs, or cash pay, that history does not count toward grandfathering the medication past the PDL’s standard placement or clinical criteria.

How to Submit

Montana Medicaid accepts prior authorization submissions three ways. Whichever you choose, confirm that every page of the form and all supporting documentation are included before it goes out.

Qualitrac Portal

The Qualitrac portal, operated by Mountain-Pacific in partnership with Telligen, is the preferred channel. It lets you submit around the clock, drag and drop supporting documents instead of faxing them, check the real-time status of pending requests, receive determination notifications by email, and retrieve prior authorization numbers from past requests.⁵ Registration forms and user guides are on the Mountain-Pacific provider portal website.⁶

Fax

Fax numbers vary by service type. There is no single fax for all prior authorization requests. Artificial disc replacement requests fax to (406) 513-1923 locally or (877) 443-2580 long-distance. Hearing aid requests go to (406) 444-1861. Transportation requests fax to (406) 443-0684 locally or (800) 291-7791 long-distance.¹ Confirm the correct fax number for your service category on the prior authorization page before sending.

Mail

Paper submissions for hearing aid and dispensing fee authorizations go to Health Policy and Services Division, Medicaid Services Bureau, DPHHS, P.O. Box 202951, Helena, MT 59620-2951.¹ Mail adds transit time, so use it only when fax and electronic options are unavailable.

When You Should Hear Back

Once the reviewing entity has a complete submission, federal regulations set the outer boundaries for a decision. For rating periods starting on or after January 1, 2026, standard prior authorization decisions in Medicaid managed care must come within seven calendar days of receipt, down from the previous fourteen-day limit.⁷ That window can be extended up to fourteen additional days if the member or provider requests it, or if the reviewer justifies a need for more information and shows the delay benefits the member.

When a provider indicates that waiting the standard timeframe could seriously threaten the member’s life, health, or ability to function, an expedited review must produce a decision within seventy-two hours of receipt, subject to the same fourteen-day extension conditions.⁷

Decisions arrive through the Qualitrac portal if you submitted electronically, or by mail to both provider and member. Montana’s medical necessity standard, at Administrative Rules of Montana 37.85.410, lets DPHHS or its review organization consider the service type, who is providing it, the setting, and any category-specific requirements when deciding.⁸

If the Request Is Denied

DPHHS sends a written notice of adverse action explaining the reason and describing appeal rights.

Often the faster route is to resubmit. If the denial cited insufficient medical necessity documentation, add detailed specialist notes, updated lab results, or a letter of medical necessity from the treating physician, and resubmit through Qualitrac.

The member or their authorized representative can also request a State Fair Hearing by submitting a written request to the Department within ninety days of the date the adverse action notice was mailed. The request doesn’t need to be signed; a clear written statement that the member wants a hearing is enough.⁹ The ninety-day deadline aligns with 42 CFR 431.221.¹⁰ Send written hearing requests to the Office of Fair Hearings, P.O. Box 202953, 2401 Colonial Drive, Third Floor, Helena, MT 59620.

If the fair hearing decision goes against the member, the next level is an appeal to the Board of Public Assistance, which must be received within fifteen days of the date the hearing decision notice is mailed, extendable to forty-five days for good cause. Judicial review can then be sought by filing in district court within thirty days of the Board’s final decision.⁹

1
Montana DPHHS. Prior Authorization Information
2
Montana DPHHS. Montana Medicaid Provider – Forms
3
Montana DPHHS. Passport to Health Manual
4
Montana Healthcare Programs. Montana Healthcare Programs Preferred Drug List
5
Montana Healthcare Programs. Prior Authorization Qualitrac Portal
6
Mountain Pacific. Montana Healthcare Provider Portal
7
eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
8
Legal Information Institute. Montana Administrative Rules 37.85.410 – Determination of Medical Necessity
9
Montana Department of Public Health and Human Services. Fair Hearings, Administrative Reviews, and Appeals
10
eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries