Montana Department Of Public Health & Human Services Coverage Criteria
- Montana Department Of Public Health & Human Services prior authorization
- All Montana Department Of Public Health & Human Services policy updates
Latest Montana Department Of Public Health & Human Services coverage criteria updates15
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Mental Health Outpatient (OP) Therapy Coverage CriteriaDefines coverage, provider and service requirements, and utilization management for mental health outpatient (individual, family, and group) therapy provided to members with a primary DSM or ICD mental health diagnosis.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Mobile Crisis Response ServicesDefines Montana Medicaid coverage, provider and service requirements, and medical necessity criteria for mobile, community-based behavioral health crisis response and stabilization services for members experiencing mental health or substance use crises.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-10-01SUD Clinically Managed Low-Intensity Residential (ASAM 3.1) — Adult and AdolescentDefines coverage, provider and service requirements, medical necessity criteria, and utilization management for ASAM 3.1 clinically managed low-intensity residential substance use disorder services for adults and adolescents under Montana Medicaid.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2015-10-01School and Preschool Required Immunizations (Coverage Criteria)Defines required vaccine doses and timing for preschool and kindergarten through 12th grade enrollment in Montana public settings; affects pupils and preschools subject to MCA and ARM vaccination rules.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2015-07-01Agency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS) Coverage CriteriaGoverns eligibility, service location, covered ADL/IADL services, limits, and attendant/provider rules for Montana Medicaid members receiving agency-based Community First Choice and Personal Assistance Services.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEff. 2014-07-01Outpatient Drugs, Fraud, Waste, and Abuse — Coverage CriteriaRequirements and controls for outpatient prescription drugs for Montana Medicaid, Healthy Montana Kids, and Mental Health Services Plan members, including fraud/abuse definitions, refill limits, prior authorization triggers, and opioid prescribing limits.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyBSW 708 Services: Big Sky Bonanza Consumer Directed Goods and Services (new number to be assigned)Defines Consumer Directed Goods and Services available to members enrolled in the member-directed Big Sky Bonanza option of the Big Sky Waiver, including coverage criteria and service requirements for purchase of goods, supports, and supplies not provided elsewhere by the waiver or Medicaid State Plan.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyBig Sky Waiver review — constituent meeting summary (coverage criteria)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.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyEvolving from Nursing Home to Community Life — Money Follows the Person (MFP) and Complex Care Add-on Coverage CriteriaThis document describes Montana DPHHS programs and policies to support Medicaid-eligible individuals moving from nursing facilities or other institutional settings back to community-based living, who are eligible for Money Follows the Person (MFP) and related waiver programs. It affects Montana Medicaid recipients, nursing facilities, case managers, and community service providers involved in transitions and post-acute care.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyGBMI Group Home Services Coverage CriteriaPolicy governs Group Home services for individuals found Guilty But Mentally Ill (GBMI) who are sentenced to the custody of the Montana DPHHS Director and placed in approved GBMI group home settings; it describes eligible individuals, provider types, and minimum service expectations.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyMedicaid behavioral health state plan services — coverage criteria (behavioral health/SDMI, TMS, TCM, DBT, IMR, PACT/MCT, Day Treatment)Defines covered behavioral health services and program descriptions for Montana Medicaid members, including service types, purposes, and delivery settings; applies to providers furnishing these services under Montana DPHHS Medicaid.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyProposed Changes to Autism State Plan — ABA services (coverage criteria)Defines proposed changes to Montana's Autism Treatment State Plan governing eligibility, authorization, service scope, settings, and assessment tools for ABA services for Medicaid members (children and youth up to specified ages). Affects Medicaid-enrolled members, providers of ABA, and the Developmental Disabilities Program administration.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicyProposed Changes to Autism State Plan: ABA Services Coverage CriteriaProposed changes to Montana's Autism State Plan governing Medicaid-covered ABA services for members up to age 21, expanding eligible diagnoses, modifying prior authorization and service unit rules, and changing caregiver presence and assessment requirements.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicySenior Companion Services (BSW 731) — Coverage CriteriaDefines Senior Companion services provided via Senior Corps/Area Agencies on Aging programs, covering intended services, requirements, limitations, and provider qualifications for Montana DPHHS members.All Montana Department of Public Health & Human Services updates
- Coverage CriteriaClinical/Medical PolicySubstance Use Disorder Targeted Case Management (SUD TCM) Coverage CriteriaDefines Montana Medicaid coverage, eligibility, provider requirements, and billing for targeted case management services for adults and youth with substance use disorder (SUD). Applies to state-approved SUD programs and enrolled case managers providing TCM for Medicaid members.All Montana Department of Public Health & Human Services updates
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Tool Description
Search Montana Department Of Public Health & Human Services coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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