Montana Medicaid uses the Medical-Surgical Prior Authorization Request for procedures reviewed by Mountain-Pacific Quality Health, its prior authorization contractor. A surgeon's office meets it when a procedure needs Medicaid approval, and one form covers all providers in the case, including assistant surgeons and the facility. Requests must be complete and include all supporting clinical documentation for prompt processing.
The requesting physician's office completes Section A (member and service type), Section B (each rendering provider's NPI, procedure codes, modifiers, date and diagnosis) and Section C (facility) when the facility's billing codes are known, plus submitter contact details.
Download the current version from the source each time; forms change without notice.
Montana Medicaid Medical-Surgical Prior Authorization Request
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. The form is designed to be used for all providers in a single case. Section B lists each performing provider, including assistant surgeons, with NPI and procedure codes, and Section C covers the facility when its billing codes are known.
All supporting clinical documentation related to the request must be submitted with the form. Montana's prior authorization page says medical-surgical requests need the member's name, Medicaid ID, the state and hospital, and medical necessity documentation, and Mountain-Pacific gives specific instructions case by case.