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Expedited Contractor Referral

  • newContractor Packet download

  • or
    Contractor can request Contractor Packets by calling:
    1-866-913-2323 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: 443-2580
    (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. 

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

  2. If patient will benefit from a consultation:
      MPQH will:
      • Assign a Prior Authorization Number
      • Fax “PA Number” form letter to Contractor or Mail the Contractor Packet and form letter “PA Number” to Contractor.

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).

Page last updated: 07/07/2009