Expedited Contractor Referral
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:
- 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.
- 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.
- 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).