Requesting Prior Authorization - Non-Acute Services
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Governs how providers request prior authorization for non-acute behavioral health and developmental disability services under Montana Medicaid and which portal and timelines apply. Affects providers submitting prior authorization requests for non-acute services.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization criteria and process
Operational criteria and decision pathways for prior authorization of non-acute services:
ALL of the following
- Clinical reviewer will complete the review within three business days of receipt of complete information.
Following review the clinical reviewer will take ONE of the following actions:
- Request additional information as needed to complete the review; provider must submit requested information within five business days of the request.
- Approve the prior authorization as medically necessary up to the maximum number of days allowed for the service; approval will generate notification to all appropriate parties if medical necessity criteria are met.
- Defer the case to a board-certified physician for review and determination if the request does not appear to meet medical necessity criteria.
Submission, Review, and Provider Responsibilities
Submission and review steps via Qualitrac — required timelines and actions
Use the Mountain‑Pacific Quality Health Qualitrac Utilization Management Portal to submit prior authorization requests for non-acute services. Do not submit requests earlier than five business days before the member’s admission — requests received earlier will be returned and must be resubmitted within the allowed window. Requests received after admission are considered from the date received. Clinical reviewers complete reviews within three business days of receiving complete information, may request additional information (providers must supply that information within five business days), approve up to medically necessary days not to exceed the service maximum, or defer the request to a board-certified physician; deferred physician reviews are completed within three business days of receipt of the information.
- Submit prior authorization requests through the Qualitrac portal only.
- Do not submit earlier than five business days prior to admission — early submissions will be returned.
- If submitted after admission, the request is processed from the date received.
- Clinical review completed within 3 business days for complete requests.
- If additional information is requested, provider must respond within 5 business days.
- Department/designee may authorize medically necessary days up to each service’s maximum; cases may be deferred to a board‑certified physician for review (physician review within 3 business days).
Key Definitions
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