Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceMontana DPHHS Big Sky Waiver Prior Auth Policy Upd…
    Ask Trek AI about this page
    CurrentMontana Department of Public Health & Human ServicesPolicy N/A

    Big Sky Waiver review — constituent meeting summary (coverage criteria)

    Customize your policy alerts

    Sign up for all Montana Department of Public Health & Human Services policy alerts

    Know when Montana Department of Public Health & Human Services releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Meeting minutes from the November 19, 2020 Big Sky Waiver constituent meeting summarizing proposed changes, issues, and analyses related to waiver services (Private Duty Nursing, Environmental Accessibility Adaptations, Nonmedical Transportation, Specialized Medical Equipment/Supplies) and implementation concerns for Montana DPHHS stakeholders and providers.

    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyBig Sky Waiver review — constituent meeting summary (coverage criteria)
    Policy CodePolicy N/A
    Change TypeProposed policy modifications and analyses
    Effective DateN/A
    Next Review DateN/A
    Key ActionDPHHS will analyze utilization and draft policy changes including lowering prior authorization thresholds for EAA and SME and clarifying PDN provider qualifications and documentation requirements.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1meeting date recorded
    4major service sections
    2prior auth topics

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ongoing
    DPHHS action items

    Coverage Criteria & Planned Modifications

    Planned policy modification areas

    Areas identified for modification or analysis (DPHHS to draft policy changes):

    Private Duty Nursing coverage issues: DPHHS will modify policy to address gaps between State Plan/EPSDT and waiver coverage to ensure members receive needed nursing services; examples cited include tasks not covered by EPSDT (e.g., set-up for feeding, post-feeding monitoring, monitoring after day surgery, wound care) and lack of Home Health availability.

    Action items: define provider qualifications (RN/LPN), clarify RN oversight documentation and frequency, specify MD order responsibilities, and clarify specially trained attendant qualifications. (DPHHS requested examples from stakeholders for analysis.)

    Environmental Accessibility Adaptations (EAA) policy changes: Shift policy focus from requiring a relation to a specific diagnosis toward functional need and prevention of institutionalization; remove diagnostic linkage requirement so eligibility is based on functional need.

    DPHHS to analyze utilization and contractor participation barriers (including two-bid requirement and payment timing) and consider lowering prior authorization threshold.

    Specialized Medical Equipment/Supplies (SME): Review prior authorization processes and thresholds; constituents raised that the 'commonly covered items' table forces prior authorization for items not listed (including low-cost items), creating confusion and inefficiency.

    DPHHS to analyze utilization data and consider reducing the prior authorization amount (discussed reduction from $5,000 to $2,500) and to pursue the grid removal project to address the table issue.

    Nonmedical Transportation and related services: Analyze authorization periods (including annual authorization) and mileage caps; examine overlap and boundaries among social supervision, medical escort, medical transportation, and nonmedical transportation to determine needed policy modifications.

    DPHHS to analyze options for person-centered mileage determination and prior authorization requirements; propose modifications based on findings.

    Current State Plan and EPSDT definitions create specific limits that can exclude routine tasks from coverage even when a member needs nursing supports in the home. Meeting participants reported examples where EPSDT will cover a nurse to feed a child but will not cover set‑up for feeding or monitoring afterward for aspiration risk, and where post‑operative monitoring after day surgery or wound care needs fall outside EPSDT skilled‑task definitions. Because waiver coverage is tied to EPSDT/State Plan skilled‑task definitions, these excluded tasks also may be excluded from Big Sky Waiver coverage, creating gaps in care.

    DPHHS is shifting how Environmental Accessibility Adaptations (EAA) are framed in policy: the focus will move from a narrow medical necessity framing to an emphasis on functional need and prevention of institutionalization. The updated language will remove the requirement that an item must relate to a specific diagnosis and instead center coverage decisions on whether the adaptation supports the member’s function and ability to remain safely in the community.

    Prior Authorization and Coding Considerations

    Prior authorization amounts discussed — proposed reductions
    Environmental Accessibility Adaptations (EAA) prior authorizationProposed reduction of prior authorization threshold from $8,000 to $5,000 (DPHHS to analyze 3 years of utilization to set final amount)
    Specialized Medical Equipment/Supplies (SME) prior authorizationProposed reduction of prior authorization threshold from $5,000 to $2,500 (DPHHS to analyze 3 years of utilization to set final amount)
    DPHHS actionAnalyze utilization over the past three years at varying cost levels to determine appropriate prior authorization thresholds

    Provider Responsibilities, Prior Auths, and Denial Risks

    Prior Authorization

    DPHHS reviewing and proposing lower prior authorization thresholds

    DPHHS is actively reviewing prior authorization thresholds and has proposed lowering Environmental Accessibility Adaptations (EAA) from $8,000 to $5,000 and Specialized Medical Equipment/Supplies (SME) from $5,000 to $2,500; utilization data over the past three years will be analyzed to set final amounts.

    • EAA discussed reduction from $8,000 to $5,000.
    • SME prior authorization amount reduced from $5,000 to $2,500 (proposal) and subject to utilization analysis.
    Step Therapy

    No step therapy policy — prior authorization table governs requirements

    No step therapy policy is described in the meeting materials; instead, whether an item requires prior authorization is governed by the prior authorization table and related thresholds.

    • Prior authorization table determines authorization needs for items; no step therapy process documented.

    Background & Policy Context

    Stakeholders flagged clinical service gaps that arise where State Plan/EPSDT definitions do not align with practical nursing needs in home and community settings. Specific examples discussed included exclusion of feeding set‑up and post‑feeding monitoring, difficulties providing adequate wound care, and growing needs for monitoring after day surgery. DPHHS stated its intent to modify policy to remove these gaps so members can receive the nursing services necessary to stay safely in their homes and communities.

    Service Definitions and Notes

    Private Duty Nursing (PDN) — scope and coverage gaps
    Definition — Private Duty Nursing (PDN)Home/community nursing service with focus on gaps between EPSDT/State Plan skilled-task definitions and waiver coverage; includes RN/LPN roles and authorization/provider qualification issues
    Coverage gaps — example tasksTasks such as setting up for feeding or monitoring after feeding, monitoring after day surgery, and certain wound care activities may not align with EPSDT skilled-task definitions and therefore may be excluded from both EPSDT and waiver coverage
    Access and staffing issuesLack of Home Health staffing or county Home Health availability can delay discharge to community or limit access to necessary nursing supports
    DPHHS actionsCollect provider-submitted examples and modify policy to remove gaps so members can receive needed nursing services to remain safely in the community
    Environmental Accessibility Adaptations (EAA) — purpose and proposed policy focus
    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyBig Sky Waiver review — constituent meeting summary (coverage criteria)
    Policy CodePolicy N/A
    Change TypeProposed policy modifications and analyses
    Effective DateN/A
    Next Review DateN/A
    Key ActionDPHHS will analyze utilization and draft policy changes including lowering prior authorization thresholds for EAA and SME and clarifying PDN provider qualifications and documentation requirements.
    SourceLink
    On This Page
    Coverage Criteria & Planned ModificationsPrior Authorization and Coding ConsiderationsProvider Responsibilities, Prior Auths, and Denial RisksBackground & Policy ContextService Definitions and Notes
    Documentation Required

    Clarify documentation, RN oversight billing (T1001UA), and MD order responsibilities

    Providers must clarify documentation and order responsibilities for PDN services, including what documentation and oversight frequency are required to bill RN oversight (T1001UA) and who is responsible for obtaining MD orders for member care needs.

    • Clarify when RN oversight T1001UA is approved and required documentation/frequency.
    • Determine whether the provider or case management team is responsible for obtaining MD orders.
    Denial Risk

    Coverage gap risk when State Plan/EPSDT definitions exclude tasks

    Services may not be covered when State Plan/EPSDT definitions exclude certain tasks (for example, set-up for feeding or post-feeding monitoring), creating a coverage gap risk where the waiver also follows EPSDT definitions.

    • Tasks not aligning with EPSDT skilled-task definitions may be excluded from both EPSDT and the waiver.
    • Examples include set-up for feeding, monitoring after feeding, monitoring after day surgery, and wound care.
    Denial Risk

    Prior authorization required for items not on the commonly covered table — risk of delays/denials

    Any items not listed on the 'commonly covered items' table require prior authorization, which has been reported to cause confusion and delays — even for inexpensive items like reachers and blood pressure cuffs.

    • Table currently forces prior authorization for non-listed items, creating administrative burden.
    • DPHHS is working on a grid removal project and will propose potential resolutions.
    Definition — Environmental Accessibility Adaptations (EAA)Home modifications intended to support function and prevent institutionalization; policy to emphasize functional need rather than relation to a specific diagnosis
    Policy emphasisShift focus from 'medical necessity' or diagnosis-based criteria to functional need and prevention of institutionalization in determining EAA coverage
    Prior authorization considerationDPHHS discussed lowering the EAA prior authorization threshold (example discussed: $8,000 to $5,000) and will analyze utilization data over 3 years to set a workable amount
    Operational barriers notedTwo-bid requirement and contractor participation/payment timing were identified as barriers to EAA implementation and will be analyzed by DPHHS