Partners in Healing
Our Medical Team is dedicated to helping injured workers heal and return to the life they love. We work closely with providers and employers to make sure care is timely, thoughtful, and tailored to each individual. With a focus on compassion, connection, and doing what’s right, we’re proud to support Montanans through every stage of recovery.
Quick Reference Contacts
Medical Team Main |
MSF Main Office |
Medical Payment Auditor |
Medical Bill Status |
| 406-495-5011 | 800-332-6102 | Susan Bomar 406-495-5271 subomar@mt.gov |
866-274-7464 |
Provider Relations Specialist |
Nurse Manager |
Medical Auditor |
Pharmacy Liaison |
| Shannon Hadley 406-495-2545 shadley@mt.gov |
Charlene Nichols 406-495-7010 chnichols@mt.gov |
Kym Vonada 406-495-5389 kvonada@mt.gov |
Sheryl Semans 406-495-5010 shsemans@mt.gov |
Contacts
Medical Auditor | Kym Vonada
406-495-5389
kvonada@mt.gov
Medical Payment Auditor | Susan Bomar
406-495-5271
subomar@mt.gov
| Getting Paid | Presumptive Authorization | National Provider Identifier (NPI) & Clean Claim | Fee Schedules |
|
Medical Bill Review and Payment Process FAQ |
Presumptive Auth FAQs: What is it? It is the process that will eliminate the need for prior authorizations for certain treatments and codes for the first 60 days of an accepted claim. Why? The goal is to reduce paperwork for you, the provider, as well as the Claims Examiners thus allowing treatment to be scheduled faster for injured workers. How does it work? For the first 60 days after a date of injury, if the claim is accepted, prior authorization is not required for this list of treatments/procedures:
https://www.montanastatefund.com/web/medical-teams/presumptive-codes.jsf
When these bills come into MSF they will be streamlined for payment and will not require approval by the claims examiner. What if I like the prior authorization process? You can keep using the prior authorization process however, MSF hopes that as you become more comfortable with the process, you will eliminate the need to fax in prior authorization requests for the presumptive authorization treatments. How do I know if a claim is accepted? You can call MSF at 800-332-6102 and ask for status or you can submit an initial prior authorization form and if treatment is approved, know that the claim is accepted, thus eliminating the need for further prior authorization forms for the 60 days after a date of injury. There will always be “one off” situations that occur and when those situations arise, please feel free to call 800-332-6102. Presumptive Authorization CPT Codes |
||
| Billing Guidelines | |||
| Please do not use a highlighter to identify information on a reconsideration request. While it is easy to see these on the document that comes in, once it gets imaged, the highlighted items are blacked out and are illegible. Also, anything written or noted in red is dropped during the imaging process so is not visible. Please circle, underline or star * the items you want noted.
When these bills come into MSF they will be streamlined for payment and will not require approval by the claims examiner. What if I like the prior authorization process? You can keep using the prior authorization process however, MSF hopes that as you become more comfortable with the process, you will eliminate the need to fax in prior authorization requests for the presumptive authorization treatments. How do I know if a claim is accepted? You can call MSF at 800-332-6102 and ask for status or you can submit an initial prior authorization form and if treatment is approved, know that the claim is accepted, thus eliminating the need for further prior authorization forms for the 60 days after a date of injury. There will always be “one off” situations that occur and when those situations arise, please feel free to call. |
Timely Filing: Effective 7/1/2022, Department of Labor and Industry (DLI) has added a new rule under the Administrative Rules of Montana (ARM) 24.29.1402(1)(c):
(c) A provider of medical treatment or services shall only be paid for services under this chapter if the bill for medical treatment or services is timely received by the employer or appropriate payer. Absent a showing of good cause, a bill for treatment or services is timely received by the employer or appropriate payer when it is actually received within 365 days of the later of: (i) The date of service; or (ii) The date the provider of medical treatment or services knew the treatment or services was related to a claim for benefits under this chapter. The entire rule can be found at: . DLI contact person is Celeste Ackerman at 406-444-6604. |
Reconsideration Requests: When submitting a request for re-evaluation or reconsideration, please be sure to attach a copy of the EOR with your submission and indicate on the billing form that it is a reconsideration request along with any additional records needed for review. If you are submitting a corrected bill, indicate on the billing form that it is a corrected bill and attach a copy of the EOR and any additional information you want to be considered. Bill Status: When calling for bill status, please call Rising Medical Solutions (RMS) first at 866-274-7464. If you need further assistance, you can call the Medical Auditors line at 406-495-5011. Please give 30 days before calling for payment status to allow RMS the maximum processing time. It is also helpful if you don’t wait to call until you have a long list to go through. These are time consuming and take a lot of busy staff time to try to reconcile. |
When an IE moves out of state and plans to seek medical treatment, providers will be paid according to the workers’ compensation fee schedule applicable to that state. Primary Care Provider (PCP) designation is not made to out of state providers. |
| Durable Medical Equipment | Therapies & Chiropractic | Montana Utilization & Treatment Guidelines | |
| In February 2021 MSF contracted with Rising DME to provide DME for injured workers. All pre-authorizations for DME that is NOT dispensed directly by a provider’s office or clinic should go directly to risingdme@risingms.com or faxed at 312-224-1327. This includes authorizations for Bone Growth Stimulators, TENS/Muscle Stimulation units and other name brand items. If you have questions regarding a pending authorization or need to relay additional information please call 888-959-0043. |
For DME that is dispensed directly from your clinic, continue to bill it out usual – it will be paid per the DLI fee schedule rules under ARM 24.29-1523: 24.29.1523 Medical Equipment and Supplies for Dates of Service on or After July 1, 2013 (1) For both facility and professional services, reimbursement for DME dispensed through a medical provider is determined by the professional fee schedule in effect on the date of service, except for prescription medicines as provided by ARM 24.29.1529. On March 31 of each year, or as soon thereafter as is reasonably feasible, the professional fee schedule with updated HCPCS will be posted on the web site. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30 percent of the cost of the item plus the freight cost. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer's request. (a) Copies of the instructions are available on the department web site or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011. (2) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a "value-added" service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable. |
Please see the Montana Professional Fee Schedule Instruction for complete information. The Rule of Eight is utilized for these services. Please see the Provider Cheat Sheet (Passive Therapeutic Procedures vs Passive Modalities) to use as a guide.
Passive Therapeutic Procedures vs. Passive Modalities |
Montana Utilization and Treatment Guidelines |
| Contacts | Surgery Formulary | Active Pharmacies | Reopening Inactive Claims |
|
Pharmacy Liaison | Sheryl Semans |
Surgery Formulary
Surgery Formulary List |
Active Pharmacies | Reopen an Inactive Claim |
Medical Providers Workers' Compensation Resources
| Contacts | Education | Medical Forums | Annual Medical Conference |
|
Provider Relations Specialist | Shannon Hadley |
Provider Training
|
Medical Forums & Webinars | Annual Medical Conference |
| Medical Service Liaisons | Independent Medical Evaluation | Impairment Rating Evaluation | Functional Capacity Evaluation |
|
Courtney Dahlquist 406-495-5314 courtney.dahlquist@mt.gov Cindy Gallus 406-495-5189 cgallus@mt.gov Shannon Mergenthaler 406-495-5185 shmergenthaler@mt.gov Maggie Pentecost 406-495-5322 mpentecost@mt.gov Jamie Statton 406-495-5286 jstatton@mt.gov |
An independent medical evaluation (IME) is an assessment performed by a physician who does not treat the patient. An IME is used to resolve questions about your medical condition for purposes of a workers’ compensation claim. Independent medical examinations may be conducted to determine the cause, extent and medical treatment of a work-related injury where liability is at issue; whether an individual has reached maximum benefit from treatment; and whether any permanent impairment remains after treatment. An independent medical examination may be conducted to obtain an independent opinion of the clinical status of the injured employee. Workers’ Compensation insurance carriers have a legal right to this request. The opinion obtained from an IME is presented to the treating provider for review and opinion. | What is an Impairment Rating? According to the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA Guides), “Impairment ratings reflect the severity of the medical condition and the degrees to which the impairment decreases an individual’s ability to perform common activities of daily living, excluding work.” In most cases, the rating is determined by evaluating loss of range of motion, loss of motor function/strength and loss of sensation. The evaluation can extend to all areas of physical and cognitive functioning. These ratings determine disability payments/benefits to injured or ill individuals. When is an impairment Rating needed? Impairment ratings are conducted by approved medical specialists to determine the permanent impact that a workplace injury will have on an employee’s health. The purpose of an impairment rating is to establish whether an employee who has filed a workers’ compensation claim is owed further benefits beyond his or her initial temporary income benefits payout. Once the physician handling the workers’ compensation case has concluded that the injured employee has reached Maximum Medical Improvement (MMI), the next step is to render the injured employee with an impairment rating. This rating will provide insight into whether an employee will receive further compensation and how much the compensation will be. Why are impairment ratings performed? Impairment ratings are often used as one of the factors in determining the settlement value of a claim. There are several indications for an Independent Medical Exam for the purposes of determining permanent impairment: • Treating physician does not perform impairment ratings. • Treating physician did not follow state specific regulatory guidelines for impairment rating calculation. • Impairment rating was not supported by objective findings. • Impairment rating does not correlate to documented injury (too high or too low). |
What is a Functional Capacity Evaluation? A Functional Capacity Evaluation (FCE) is an evaluation of a person's functional capacity in relation to a job's demands. The FCE involves aspects of lifting, carrying, pushing/pulling, balance, fine motor, and cardiovascular tolerance. In accordance to the response to these activities, a capacity is determined which is based upon the US Department of Labor's Dictionary of Occupational Titles (DOT). When is a Functional Capacity Evaluation indicated? 1. There has been no functional progress with treatments. 2. Discrepancies between the subjective complaints given and objective findings present. 3. Injured employee shows difficulty in returning to gainful employment. 4. A determination of functional capacities is needed to plan for job placement and/or resolve a claim. |
| Medical Status Form | Provider Request for Authorization | Primary Care Provider Designation (PCP) | Montana Utilization and Treatment Guidelines |
| Medical Status Form | Provider Request for Authorization | PCP Defined: A designated Primary Care Provider (PCP) or designated treating physician is a provider that is primarily responsible for delivery and coordination of the injured employees' medical services for treatment of a workers' compensable injury or occupational disease and is: a physician, chiropractor, physician assistant, osteopath, dentist, or advanced practice registered nurse; licensed by the state of Montana. PCP Role: The PCP is responsible for coordinating the worker's receipt of medical services as provided; shall provide timely determinations required under this chapter, including but not limited to maximum medical healing, physical restrictions, return to work, and approval of job analyses, and shall provide documentation; shall provide or arrange for treatment within the utilization and treatment guidelines or obtain prior approval for other treatment; and shall conduct or arrange for timely impairment ratings. PCP Scope: The PCP may refer the worker to other medical providers for medical services, for the treatment of a worker's compensable injury or occupational disease. A medical provider to whom the worker is referred by the PCP is not responsible for coordinating care or providing determinations as required of the PCP. PCP Reimbursement: The designated PCP must be reimbursed at 110% of the department's fee schedule. A medical provider to whom the worker is referred by the PCP must be reimbursed at 90% of the department's fee schedule. A medical provider providing care on a compensable claim prior to the designation of the PCP by the insurer must be reimbursed at 100% of the department's fee schedule. |
Montana Utilization and Treatment Guidelines |
| Telehealth | Out of State Medical Treatment |
| Telehealth Guidelines | When an IE moves out of state and plans to seek medical treatment, providers will be paid according to the workers’ compensation fee schedule applicable to that state. Primary Care Provider (PCP) designation is not made to out of state providers. |