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Patient Self Referral

Patient Self-Referral

How to Apply:

To request a Patient Packet call:

(866) 913-2323 Toll Free in MT
or
(406) 444-0440 Helena/Out-of-State
Request for a Patient Packet can be made by the patient, healthcare professionals, family, friends or caregivers.
 

Complete the Patient Packet, sign pages 6 and 7 and return in the envelope provided or to:

Mountain-Pacific Quality Health
ATTN: Montana PharmAssist
3404 Cooney Drive
Helena MT 59602

MPQH analyzes Patient Packet 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 form letter “Will Not Benefit” to the patient.
  • If patient will benefit from a consultation:
    • MPQH will:
      • Assign a Prior Authorization Number.
      • Fax or mail "PA Number" form letter, completed Patient Packet, and Part II Patient Packet (includes the “Initial Consultation Invoice” form)to a Contractor.

If more than one Contractor is in the patient area, MPQH will refer to the Contractor requested by the patient or if none requested select the Contractor randomly.

Steps for Consultation and Reporting Requirements:

  1. Contractor receives completed Patient Packet, Part II Patient Packet and “PA Number” form letter. 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 participating pharmacist then has 1 week to mail the following to MPQH:
  • Completed “Initial Consultation Invoice”. MPQH will approve the Invoice and forward to the MT PharmAssist Supervisor for payment processing.
  • Patient Packet.
  • Copy of recommendations 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 participating pharmacist 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).