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Expedited Contractor Referral

Expedited Contractor Referral

Contractor Packet download

or
Contractor can request Contractor Packets by calling:
(866) 913-2323 Toll Free in MT
or
(406) 444-0440 Helena/Out-of-State

Contractor and patient fill out Pages 3-7 completely, and Fax or mail for Prior Authorization Number to:

Fax: 457-3058
(please include a cover sheet with a return fax number)
or
Mountain-Pacific Quality Health (MPQH)
Attn: Montana PharmAssist
3404 Cooney Drive
Helena MT 59602

MPQH analyzes the patient information to determine if there is an opportunity for the patient to benefit from the program.

  • If patient will not benefit from a consultation, MPQH will:
    • Mail the patient the form letter “Will Not Benefit”.
    • Fax or mail the Contractor the form letter “PA# Not Issued” indicating that a Patient Authorization Number will not be generated and why
  • If patient will benefit from a consultation, MPQH will:
    • Fax “PA Number” form letter to Contractor or Mail the Contractor Packet and form letter “PA Number” to Contractor.
    • Assign a Prior Authorization Number

Steps for Consultation and Reporting Requirements:

  1. If faxed the “PA Number” form letter or, if mailed, Contractor receives Contractor Packet and form letter “PA Number”. Contractor contacts patient to arrange face-to face.
  2. Contractor performs face-to-face patient Initial Consultation within 2 weeks* after receiving packet.
    • *To request additional time – Contractor calls DPHHS Pharmacist (406) 444-5951.
  3. After the Initial Consultation the Contractor has 1 week to mail the following to MPQH:
    • Completed “Initial Consultation Invoice” page 14. MPQH will approve the Invoice and forward to the MT PharmAssist Supervisor for payment processing.
    • Contractor Packet pages 3 – 4.
    • Signed by patient, “Notice of Protected Health Information” (Contractor Packet pages 5-6).
    • Signed by patient, “Authorization for the Use and Disclosure of Health Information” (Contractor Packet page 7).
    • Part II Contractor Packet pages 11-13
    • Copy of recommendation letters and care plan for patient and healthcare provider(s).

If Follow-up Consultation is requested by the Contractor on the returned completed “Initial Consultation Invoice”:

  • MPQH will indicate approval or disapproval of the requested follow-up in the section provided on the “Initial Consultation Invoice” and forward the “Initial Consultation Invoice” to the MT PharmAssist Supervisor for payment processing.
  • If approved the MT PharmAssist Supervisor will mail the “Follow-up Consultation Invoice” form to the Contractor.

Upon completing the Follow-up Consultation, the Contractor will mail the following to MPQH:

  • Completed “Follow-up Consultation Invoice” form.
  • Copy of follow-up recommendation letter(s) for patient and healthcare provider(s).

If additional Follow-up Consultation is requested on the “Follow-up Consultation Invoice”: (Repeat as needed.)

  • MPQH will indicate approval or disapproval of the additional follow-up in the section provided on the “Follow-up Consultation Invoice” form and forward to the MT PharmAssist Supervisor for payment processing
  • If approved the MT PharmAssist Supervisor will mail the “Follow-up Consultation Invoice” form to the Contractor.

Upon completing the Follow-up Consultation, the Contractor will mail the following to MPQH:

  • Completed “Follow-up Consultation Invoice”.
  • Copy of follow-up recommendation letter(s) for patient and healthcare provider(s).