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Montana Medicaid General Use Prior Authorization Form

Montana Medicaid offers a one-page, line-item request for services that do not have their own prior authorization form. A provider meets it when a Montana Healthcare Programs service needs approval and no service-specific form applies. Up to 15 lines carry dates, type of service, procedure and diagnosis codes or ranges, and the units and dollars requested, and the reviewer signs the approval.

Who completes it

The billing or rendering provider completes the client name and ID, provider details and each service line, marking whether it is a new request or a change to an existing PA number. The approver signs and adds an approver ID and date.

Submitting and payment

How to submit it
Send it to the prior authorization reviewer for the service type listed on Montana Medicaid's Prior Authorization Information page. Mountain-Pacific Quality Health handles most services, while hearing aids go to the DPHHS Health Policy and Services Division.

Good to know

  • Mark New for a first request, or Change with the existing PA number to amend an authorization already on file.
  • Each line has columns for type of service code, procedure code or range, modifier, diagnosis code or range, tooth number and surface, maximum units, maximum dollars and a reason code.
  • Physician-administered drug requests go through Mountain-Pacific's Qualitrac portal. Medical-surgical requests have their own Mountain-Pacific form, revised 11/2018.
  • The form dates from 01/2008. Montana Medicaid is fee-for-service without managed care plans, so the state's PA forms apply to all members.

Get the official form

Download the current version from the source each time; forms change without notice.

General Use Prior Authorization Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When do I use Montana's General Use Prior Authorization Form?

Use it for a Montana Healthcare Programs service that requires prior authorization but has no dedicated form. Montana posts separate forms for medical-surgical procedures, DME, EPSDT, eyeglasses and contact lenses, hearing aids, orthodontia, orthognathic surgery and private duty nursing.

Who reviews Montana Medicaid prior authorization requests?

The Department or a prior authorization contractor. Mountain-Pacific Quality Health reviews most services, including DME, medical-surgical procedures, rehabilitation and transplants; hearing aids go to the DPHHS Health Policy and Services Division, and physician-administered drugs are submitted in Mountain-Pacific's Qualitrac portal.