Montana Medicaid uses this two-page request when a member age 20 or younger needs treatment, services, supplies or drugs beyond standard coverage under EPSDT. The child's primary care provider or specialist answers three clinical questions and signs an attestation of medical necessity. Each request is reviewed case by case, by the Medicaid pharmacist for drugs or by Mountain Pacific for everything else.
The child's primary care provider or a medical specialist acting within their scope of practice answers the clinical questions and signs the attestation with an NPI. The form also names a contact person with telephone and fax for follow-up.
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EPSDT Prior Authorization and Certification of Medical Necessity
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The child's primary care provider or a medical specialist within their scope of practice submits it when additional treatment, services or supplies are needed for a primary health condition. The signer attests to having examined the child or reviewed the medical record on a stated date.
Page 2 asks why the child needs the requested additional services, how they will ameliorate the child's condition, and which specific goals or objectives cannot be met without them. Extra pages can be attached, and the attestation confirms the services are not for cosmetic purposes or convenience.
The form states that EPSDT services are offered to children up to and through age 20. Requests for those members are reviewed case by case, and each goes through the channel for its service type: fax to the Medicaid pharmacist for drugs, or the Mountain Pacific Provider Portal for other services.