Children's Mental Health Provider Forms

Effective January 1, 2020, in partnership with Telligen, Mountain-Pacific will provide the utilization and review of behavioral health services provided by Children's Mental Health.  Please check out the Mountain Pacific Website for forms, education, training and contact information.

Appeal Forms

• Provider Administrative Review Request Form
• Claimant Fair Hearing Request Form

Acute Hospital

• Out of State Acute Inpatient Hospital Prior Authorization Request Form

Home Support Services

• Home Support Services Authorization Request After 365 Days of HSS Services 
• Home Support Services Exception to HSS Admission Criteria Request
• Discharge Notification Form TGH/HSS

Integrated Co-Occurring Treatment (ICT)

• ICT Prior Authorization Request

Mountain Pacific Quality Health Forms for Psychiatric Residential Treatment Facilities

• Youth Prior Authorization Request Form Psychiatric Residential Treatment Facility (PRTF)
• Youth Continued Stay Authorization Request Form Psychiatric Residential Treatment Facility (PRTF)
• Youth Discharge from Services Notification Form
• Youth Certificate of Need for Psychiatric Residential Treatment Facility (PRTF)

Non-Medicaid Services Forms

• Non-Medicaid Services including Room and Board Application and Attestation effective 10/14/2017

Partial Hospital Program

• Partial Hospital Program Initial Stay Request Form
• Partial Hospital Program Continued Stay Request Form

Psychiatric Residential Treatment Facilities (PRTF/PRTF-AS)

• Therapeutic Home Visit Over Three Days Request
• Interstate Compact Financial/Medical Plan
• ICPC 100A - Interstate Compact on the Placement of Children Request
• ICPC 100B - Interstate Compact on the Placement of Children Report on Child's Placement Status

Serious Emotional Disturbance (SED) Diagnosis

• Montana Scale for Children/Adolescents with Serious Emotional Disturbance (SED) Checklist

Therapeutic Group Home

• Therapeutic Group Home Continued Stay Request
• Extraordinary Needs Aid (ENA) Request For Youth in TGH 
• Discharge Notification Form TGH/HSS
• Therapeutic Home Visit Over Three Days Request
• Therapeutic Group Home Initial Stay Request
• Emergency 72 hr TGH Payment Authorization Request
• Therapeutic Group Home Transfer Form

Youth Genetics Testing for Mental Health

• Youth Genetics Testing for Mental Health Request Form