Provider Newsletter

Stay informed! Here’s the latest edition of our provider newsletter – online so you can always find your copy. Click each topic below to read the article.

March 2019 Newsletter

November 2018 Newsletter

Introducing Vice President, Jeff Crouch

We are pleased to announce the appointment of Jeff Crouch as Vice President at MHC! For the past two years Jeff has developed the Idaho Medicaid program reform strategy while at the Idaho Department of Health and Welfare. Prior to that, Jeff was at Blue Cross of Idaho for 15 years as the executive responsible for provider services, pharmacy and other functions. He brings decades of experience in the health care industry that is sure to benefit our MHC providers and members.

Improved Directory Search Features

To make it faster for members to find a participating provider—or for you to make referrals, we’ve added a new field to our Provider Finder tool. “Provider Type” lets you choose to see All types of providers or only Medical or Behavioral Health specialties. Looking for a specific type of facility? Click the “Facility” button and then the dropdown arrow next to “Facility Type.”

Nondiscrimination in Credentialing

MHC does not make contracting or credentialing decisions based on an applicant’s race, ethnic/national identity, gender, age, sexual orientation, or patient type in which the applicant specializes. Additionally, we do not prohibit or restrict providers from acting within their lawful scope of practice or discriminate against health care professionals who serve high-risk populations or specialize in the treatment of costly conditions.

Refer Patients to Our Care Manager Nurses

Care manager nurses help people with their health care and community service needs—at the right time, in the right setting, and for the best value. We strive to be respectful of the cultural and linguistic preferences of our members and their supports.

Our Care Management program offers members individual attention to help meet their health care goals. Services include education, advocacy, and coordination of needed services. This program is provided with no out-of-pocket costs to our members who want care management nursing services.

For more information or to request care management services for one of our members, call the Care Management team at 801-587-6480 option 2.

Consider Alternatives to Carisoprodol (Soma®)

In alignment with strategies to reduce the abuse of opioids, carisoprodol (Soma®) is not in the Preferred Drug List for most plans. Please consider prescribing other skeletal muscle relaxants with safer pharmacologic profiles as a treatment option for our members.

Prior Authorization Tips for Orthopedic/Spinal Procedures

To ensure appropriate evidence-based care for members, most health plans require prior authorization on certain services. Different plans may have differing requirements, making prior authorizations an often-cumbersome reality for offices. To make the approval process more efficient, reduce time and staff burden, and improve the experience for you and our members, follow these tips when requesting prior authorizations:

Urgent Requests
Some provider offices feel as if marking every request as urgent will speed the determination turnaround time. It can actually slow the review process. MHC receives many requests for conditions present for months or years with a request for an “urgent” review. All urgent requests are triaged by physicians who determine if the “urgent” request actually meets the mandates set by regulatory bodies for urgent determination. These requirements stipulate that for a request to be urgent a determination requires immediate action; although it may not be a life-threatening circumstance, an urgent situation could seriously jeopardize the life or health of the covered member, the ability of the member to regain maximum function or—in the opinion of a physician with knowledge of the claimant’s condition—would subject the member to severe pain. An urgent care condition is a situation that has the potential to become an emergency in the absence of treatment.

Many offices and patients consider every situation may be interpreted to be “urgent” but realistically, chronic conditions in which a turnaround time for a decision of 14 days or less is appropriate are best marked as routine. Our standards require a determination in not more than 14 calendar days, provided we have adequate information.

Scheduling procedures/diagnostic studies requiring review too soon
As noted above, if an urgent request is reclassified as routine and a procedure is scheduled for three days later, the authorization may not have been completed. Routine review time frames are 14 calendar days, though we strive to complete reviews as quickly as possible. Given the volume of prior authorization requests we receive, it is not always possible to get routine reviews on elective procedures or testing completed in less than 10 to 14 days. Scheduling the requested procedure 14 or more days after the request will avoid the need to reschedule the patient.

Though MHC works hard to meet members and providers’ desired schedule, scheduling alone does not meet the definition of urgent. Cases submitted as urgent for this reason will be reclassified as “routine.”

Sending all necessary documentation with your prior authorization request
The most common reason for an initial denial of service is the lack of necessary documentation to approve the request. Sending only the most recent progress note often times leaves important information out of the consideration process. Though it may take some additional effort upfront to acquire notes from referring providers or physical therapists, providing documentation of previous conservative therapy can help ensure your prior authorization request is reviewed appropriately the first time.


Including detailed information on conservative therapy
Though not all orthopedic procedures or diagnostic testing require conservative therapy, many do. For musculoskeletal services, many criteria require evidence that conservative therapy has failed.

Conservative therapy guidelines require a minimum of the following therapies:

  • Three weeks of NSAID medications
  • At least six weeks of physical therapy
  • At least six weeks of activity modification

Documentation must be specific – Without the necessary detail, the request may be denied for lack of conservative therapy when this therapy indeed may have occurred. Too often, the only conservative therapy noted is that the patient has been sent to physical therapy, but no outcomes are reported.

Providing either physical therapy notes, or a summary of the outcome and duration of physical therapy enables us to more accurately review the request the first time.

Conservative therapy needs to be temporally appropriate – Make sure notes reflect the timeliness of the conservative therapy in relation to the request (e.g., therapy performed two years ago may not be relevant to the current request).

NSAID use needs to be routine and prescription strength – Documentation should not simply note that the patient has been “taking ibuprofen”, taking “Aleve,” or taking a product “prn.” The requirement for NSAIDs is not for pain relief as much as for anti-inflammatory effect. This requires routine use of a prescription-strength medication to achieve. Patients may use over-the-counter NSAIDs, but the dose should be equivalent to a prescription strength (e.g., 500 mg of naproxen or 800 mg of ibuprofen).

Provide documentation of physical therapy outcomes – The most commonly missed documentation are notes documenting the character, frequency, duration, and outcomes from physical therapy specific to the request. Including these notes in the initial request greatly expedites the review. In lieu of physical therapy notes, duration of physical therapy and a summary of the outcome will assist us in making the most appropriate determination.

The cost of health care in the United States continues to rise and many patients simply cannot afford the care they need. Prior authorization to ensure appropriate utilization is a valuable tool to help contain those costs and keep necessary care available to all members of our community. We appreciate the opportunity to partner with you to provide quality care to our members, your patients.

General Criteria for MRI

MHC uses InterQual® criteria when making medical-necessity determinations. These criteria are evidence-based and designed to ensure appropriate utilization of medical procedures. MRIs are costly and, because many patients have high deductible health plans and will pay the entire cost of testing, we appreciate your efforts toward only ordering imaging that is medically necessary.

General guidelines to support medical-necessity criteria:
These are decision-making guidelines to help you evaluate whether an MRI is the best option.

  • Clinically appropriate? Ordering an MRI because “the patient requests MRI of XXX” will likely result in a denial.
  • Evaluate suspected progression? Ordering an MRI for a chronic problem with no changes in signs or symptoms will often result in a denial of Chronic back pain, neck pain, and headaches with no new symptoms are classic examples.
  • Diagnostic need? Many criteria require that a plain film of the area be done with results available before proceeding to an If the plain film has findings that explain the complaint, the MRI will be denied. Osteoarthritis of the knee is a common example: Pain in the knee – OA on plain film – No other issue – MRI of knee ordered. This will be denied because there is no diagnostic need for advanced imaging.
  • Film results support need? Ordering the plain film and MRI at the same time, meaning the plain film results are not available, will usually end up with a denial of coverage.
  • Required for treatment decision? Make it clear in your assessment how the MRI result will alter your treatment decision.
  • Required for referral? If an MRI is a requirement for getting an appointment with a specialist, but the clinical scenario does not meet criteria, the MRI will not be approved. Talk to the specialist if they have this as a “referral rule,” or consider using a different specialist.
  • Supported by lab results? Many criteria require that a lab diagnostic evaluation has been undertaken first (e.g., MRI of the pituitary). The pertinent lab results need to be available.


General criteria for some of the most commonly ordered MRIs:

Lumbar Spine

  • Suspected lumbar disk herniation or foraminal stenosis

Requires radiculopathy plus either of the following:

  • Motor Deficit – Must have either severe motor weakness documented (scale 1-5) or less
  • severe motor deficit which does not improve on reevaluation
  • Sensory Deficit – must have one of the following:
    • Severe pain (documented on scale of 1-10) which does not improve with conservative treatment for ≥ 3 days
    • Less severe pain refractory to NSAIDs, six-week physical therapy, and activity modification
    • Paresthesia in a nerve root distribution, worsening on reevaluation
  • Suspected cauda equina – Document suspicion of, and symptoms consistent with, cauda equina (e.g., bilateral lower extremity weakness/numbness, bowel/bladder involvement, saddle anesthesia, sphincter tone)
  • Suspected Spinal Stenosis – Document suspicion of spinal stenosis. Document: Is pain worse with walking? Improved with forward flexion? Failure of conservative treatment?
  • Nonspecific back pain with no neurologic deficits – Evidence does not support



  • Suspected unstable meniscus – Document suspicion of unstable meniscus tear, locking, and positive McMurray
  • Suspected stable meniscus tear – Document effusion, joint tenderness, knee giving way, pain with flexion and rotation, AND failure of conservative therapy
  • Suspected ACL tear – Document knee giving way by history, as well as degree of instability on physical exam
  • Collateral ligament MCL/LCL – Document degree of instability on physical exam
  • Chronic knee pain of undetermined etiology – Document locking, giving way, joint tenderness, effusion, crepitus, AND both of the following:
    • Findings of plain films
    • Failure of conservative therapy


  • Suspected acute rotator cuff tear – Document traumatic event, pain, weakness, active and passive ROM findings, AND findings on plain film
  • Suspected chronic rotator cuff tear – Same as for an acute tear PLUS failure of conservative therapy
  • Suspected labral tear – Document injury, pain interfering with ADLs, popping, catching, clicking, crank test, compression test, anterior slide test, AND both of the following:
    • Findings on plain film
    • Failure of conservative therapy
  • Chronic shoulder complaints – Document if applicable: joint pain, locking, pain with ROM, limited ROM, crepitus, AND both of the following:
    • Plain film findings
    • Failure of conservative therapy


  • Suspected femoroacetabular impingement or acetabular labral tear – Document joint pain, giving way, locking, clicking, pain with ROM, limited ROM, weakness, AND findings on plain films
  • Chronic hip pain – Document joint pain, giving way, locking, clicking, pain with ROM, limited ROM, weakness, AND both of the following:
    • Findings on plain films
    • Failure of conservative therapy


  • Time for authorization of services can be up to 14 calendar Marking a request as urgent will not change the processing time unless urgency is for a medical reason (not scheduling).
  • Include documentation of required criteria with your initial request to optimize the review
New Dedicated Fax Numbers for Prior Authorization

Please use this new FAX number for only Inpatient Admission authorizations. This new FAX is in addition to the old to help streamline inpatient admissions.

Inpatient FAX 801-262-0103

Other PA FAX 801-213-1358

Prior Authorization Phone 801-587-2851

Electronic Prior Authorization - Updates, Including Confirmation of Receipt Coming Soon!

MHC is in the process of creating an electronic Prior Authorization form. When providers submit their PA request form electronically, they will get a notice saying their request has been received and will be responded to by the adequate time frame.

September 2018 Newsletter

New Chief Executive Officer

Richard Miltenberger is the new CEO for Montana Health CO-OP. Miltenberger brings 30 years of experience in finance and marketing, including senior positions with other health insurers. Most recently, he served as President and CEO of InterWest Health, a regional physician network. Miltenberger and his wife, Katrina, reside in Clancy. They have six adult children and seven grandchildren.

Fee Schedules

MHC fee schedule rates are based on the CMS published rates effective January 2018 and are updated annually on January 1.

Access Assistance Program

MHC members can call our Access Assistance line at 801-587-2851 to help find a provider, transition to an in-network provider or schedule an appointment. We can help members locate a provider in their neighborhood or a location of their choice. We also have a team of registered nurses available to assist members in coordinating their health care needs. If you would like our Care Managers to coordinate member appointments with your clinic, please contact MHCs Provider Relations department at 801-587-6480 Option 2  or and include a clinical or scheduling point of contact.

Prior Authorization List and Request Form

Click here for the Prior Authorization Request Form.

  • Ambulance for non-emergent services
    • Transportation by fixed-wing aircraft (plane)
    • Elective (non-emergency) transportation by ground, ambulance or medical van
  • Autologous chondrocyte implantation
  • BRCA testing (genetic testing for breast cancer risk)
  • Cochlear device and/or implantation
  • Dialysis visits
  • Dorsal column (lumbar) neurostimulators: trial or implantation
  • Electric or motorized wheelchairs and scooters
  • Gastrointestinal (GI) tract imaging through capsule endoscopy
  • Hip surgery to repair impingement syndrome
  • Hyperbaric oxygen therapy
  • pre-implantation genetic testing
  • Injectables
    • Antineoplastic Agents for non-emergent services
    • Antigout Agents for non-emergent services
    • Blood-Clotting Factor Injectables for non-emergent services
    • Bone Resorption Inhibitors
    • Alpha 1-proteinase inhibitor (human)
    • Antiemetics for non-emergent services
    • Botulinum toxins
    • Cardiovascular — PCSK9 inhibitors
    • Corticosteroids
    • Enzyme replacement drugs
    • Erythropoiesis-stimulating agents for non-emergent services
    • Functional Gastro-intestinal Disorder Drugs
    • Granulocyte-colony stimulating factors
    • Growth hormone
    • Hepatitis C drugs
    • Hereditary angioedema agents for non-emergent services
    • HER2 receptor drugs
    • Hormones and Hormone Modifiers
    • Immunoglobulins for non-emergent services
    • Immunologic agents for non-emergent services
    • Injectable infertility drugs
    • Osteoporosis drugs
    • PEGylated interferons
    • Pulmonary arterial hypertension drugs for non-emergent services
    • Respiratory injectables for non-emergent services
    • Viscosupplementation
  • Inpatient confinements (all)
    • Such as, surgical and nonsurgical confinements; confinements in a skilled nursing facility; mental health rehabilitation facility; substance abuse rehabilitation facility; and maternity and newborn confinements that exceed the standard length of stay (LOS)
  • Gender Reassignment Surgery
  • Lower limb prosthetics
  • Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
  • Observation stays more than 24 hours
  • Osseointegrated implant
  • Osteochondral allograft/knee
  • Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids
  • Proton beam radiotherapy
  • Reconstructive or other procedures that may be considered cosmetic
    • Blepharoplasty/Canthoplasty
    • Breast reconstruction/breast enlargement
    • Breast reduction/mammoplasty
    • Cervicoplasty
    • Excision of excessive skin due to weight loss
    • Lipectomy or excess fat removal
    • Surgery for varicose veins, except stab phlebectomy
  • Referral or use of nonparticipating physician or provider for non-emergent services, unless the member understands and consents to the use of a nonparticipating provider under their out-of-network benefits when available in their plan
  • Spinal procedures
    • Artificial intervertebral disc surgery
    • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
    • Spinal fusion surgery
  • Transplants
  • Uvulopalatopharyngoplasty, including laser-assisted procedures
  • Ventricular assist devices for non-emergent services

August 2018 Newsletter

Risk Adjustment Campaign In-Process

MHC sent letters to providers with a list of MHC members they serve in order to encourage the completion of member annual wellness vsits (AWV). Studies have demonstrated that staying up-to-date with AWVs has a direct effect on reducing future hospitalizations and improving member health. Please schedule your patients for their AWV – contact MHC if we can assist in the process.

Monitoring Persistent Medications

MHC has evaluated our membership and is contacting providers on behalf of members who are taking ACE inhibitors/arb medications or diuretic medications, which require annual lab testing for serum creatinine and serum potassium. As of August, we do not show that these lab panels have been obtained for the members on identified in the letter sent to providers. Please schedule these members for appropriate testing right away.

September is National Cholesterol Education Month

September is National Cholesterol Education Month, a good time to get your blood cholesterol checked and take steps to lower it if it is high. National Cholesterol Education Month is also a good time to help your patients learn about lipid profiles and about food and lifestyle choices that help them reach personal cholesterol goals. Visit the website highlighted below to find a few fact sheets and publications about cholesterol.

Please review these information sources by clicking here.

June 2018 Newsletter

View Claims Online

Providers are able to view claim status and request adjustments at MHC’s Provider website. Your team may access this area on the website via the Providers drop-down menu – access this site by clicking here.

Smoking Cessation

MHC has partnered with St. Luke’s Health Systems to provide outreach to our Members in regarding to tobacco cessation efforts. MHC is working to improve these rates by providing information and incentives to our members who obtain needed vaccines. Our 2nd annual vaccination program begins in July and runs through November 2018.  If you have questions regarding this effort, please contact Robbie Roberts our Quality Director @ 208-328-7003.

June is National Safety Month

We can all use the month of June to raise awareness about important safety issues.  Together, we can share information about steps people can take to protect and reduce the risk of injury for themselves and for others. It’s the season for unpredictable and potentially dangerous weather events.  Know what disasters and hazards could affect your area, how to get emergency alerts, and where to go if your patients need to evacuate.

Check out the website to learn what to do before, during and after each type of emergency.

May 2018 Newsletter

MHC Provider Portal

Providers have their own portal to access information relating to Prior Authorizations and Appeals, MHC’s Provider Manual, and Claims Submission process. Make sure to access this area on the website via the Providers drop-down menu – for a quick trip, access this site here.


MHC Policies and Forms

MHC has partnered with the University of Utah Health Plans in 2018. If you have questions on anything from the correct form for prior authorizations or a formulary exception to understanding MHC’s Utilization Management Medical Policies, we have just the information for you and your staff. Access this information at and click on the Providers drop-down to access the Policies and Forms section of the course site – here’s the spot!

Depression Screening

Approximately half of adults are being screened for depression even though the U.S. Preventive Services Task Force recommends universal screening, according to a new AHRQ study published in the Journal of the American Board of Family Medicine. Data from AHRQ’s Medical Expenditure Panel Survey showed that, among adults 35 and older in 2014-15, depression screening was less likely for patients who were male, older than 75, racial minorities, uninsured or had a high school education or less. Access the abstract here.


April 2018 Newsletter

Enrollee Experience Survey

Your MHC patients may receive surveys in the mail that will ask them questions about their satisfaction with MHC, their healthcare provider or their overall health. This is a tool that MHC uses to monitor the quality of our members’ care in our health plan. We use these surveys to improve the care that they receive as an MHC member, so if they mention the survey, please encourage them to complete it – we would be very appreciative!

NCQA Accreditation

MHC underwent a triennial accreditation survey through the National Committee for Quality Assurance (NCQA) in January-February 2018. The results? MHC passed, scoring 97.1% (48.55 out of 50 points) on the over-300 quality standards established by NCQA for health plans. MHC’s commitment to quality begins with establishing processes that benefit our members and engage our providers. If you would like additional information on MHC’s Quality Program, contact our Quality Director, Robbie Roberts at 208-328-7003 or Click here for a copy of our 2018 NCQA Accreditation certificate.

2018 NCQA Patient Health Management Standards

As part of our ongoing commitment to quality, MHC is developing Patient Health Management (PHM) processes in conjunction with new NCQA standards. The PHM category is a shift from evaluation of a single-disease state towards a whole-person focus. Within the PHM category, health plans describe their strategy for addressing the needs of members, then demonstrate effective execution of that strategy.

The updated standards combine important components of population health management such as wellness and complex case management. These standards align with MHC’s vision where providers are engaged to improve population health, to improve individual healthcare, and control healthcare spending. The PHM category includes the following standards:

PHM 1: PHM Strategy (NEW)
Plans describe their comprehensive PHM strategy—targeted populations, programs, services and activities offered to members, in addition to demonstrating that they provide basic program information to members and instructions for using program services.

PHM 2: Population Identification (NEW)
Plans integrate data to identify and assess the needs of members and connect them with appropriate programs or services.

PHM 3: Delivery System Supports (NEW)
Plans demonstrate how they support providers or practitioners in their delivery system—providing data directly to ACOs or providing practice transformation support to budding PCMHs—and demonstrate that they engage providers and practitioners in value-based payment arrangements.

PHM 4: Wellness and Prevention
Plans identify members’ health risks and educate them about heathier lifestyles through evidence-based tools.

PHM 5: Complex Case Management
Plans offer case management services to their most complex, highest-risk members.

PHM 6: Population Health Management Impact (NEW)
Plans conduct a comprehensive analysis of their PHM efforts, to determine the effectiveness of their strategy. Analysis includes measures related to clinical processes or outcome, member experience and cost/utilization.

Contact our Quality Director, Robbie Roberts, with any questions regarding these new standards.

December 2017 Newsletter

AHRQ Stats: Highest Hospital Readmission Rates for Certain Conditions

Thirty-day all-cause hospital readmission rates in 2014 were highest for patients with congestive heart failure (23.2 per 100 admissions), schizophrenia and other psychotic disorders (22.9), and respiratory failure (21.6).

In 2018, MHC is undertaking a Hospital Readmission pilot project designed to reduce readmissions for our Members.

For more, review AHRQ’s Healthcare Cost and Utilization Project Statistical Brief #230: A Comparison of All-Cause 7-Day and 30-Day Readmissions, 2014

Complete Health Improvement Program (CHIP)

The Complete Health Improvement Program (CHIP) is an affordable, lifestyle enrichment program designed to reduce disease risk factors through the adoption of better health habits and appropriate lifestyle modifications.

The goal is to lower blood cholesterol, hypertension, and blood sugar levels and reduce excess weight. This is done by improving dietary choices, enhancing daily exercise, increasing support systems and decreasing stress, thus aiding in preventing and reversing disease.

In 2018, MHC is implementing a pilot project aimed to help our members reduce blood pressure, blood sugar and cholesterol values through this program.

Find out more information on CHIP here

September 2017 Newsletter

Substance Use and Mental Health Issues

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) latest National Survey on Drug Use and Health (NSDUH) report provides the latest estimates on substance use and mental health in the nation, including the misuse of opioids across the nation. Opioids include heroin use and pain reliever misuse. In 2016, there were 11.8 million people aged 12 or older who misused opioids in the past year and the majority of that use is pain reliever misuse rather than heroin use—there were 11.5 million pain reliever misusers and 948,000 heroin users.

The complete findings for the NSDUH report issued are available, by clicking here.

Healthy Aging and National Recovery Month

In recognition of Healthy Aging Month and National Recovery Month, FDA’s Center for Tobacco Products has created some social media content and shareable images highlighting the impact of tobacco use on health.

National Recovery Month is a national observance held every September to educate Americans that substance use treatment and mental health services can enable those with a mental and/or substance use disorder to live a healthy and rewarding life.


Read more and get the tools, by clicking here.

August 2017 Newsletter

MHC Childhood Immunization Strategy

MHC has implemented a strategy encouraging members to obtain childhood immunizations for their children. As an added incentive, MHC is providing a $25 gift card to members who provide us the vaccination records. MHC members receive vaccinations at no charge as immunizations are covered free of charge.

Access this information here: August Member Newsletter

Childhood Obesity

HHS Secretary, Dr. Tom Price, indicates that 1 in 5 American children are obese and is asking all parents to encourage physical activity and good nutrition as both are needed for a healthy lifestyle. The Presidential Active Lifestyle Award promotes improved health through USDA’s SuperTracker online food and activity tracking tool.

Read more, here: Overweight & Obesity CDC

HEDIS 2018

“I thought HEDIS was over?” MHC is already preparing for HEDIS 2018 by contacting providers regarding our efforts to streamline records collection during the Medical Record Review process. Contact Robbie Roberts, MHC’s Quality Director with questions on how to prepare staff to meet this federal requirement.

Read more, here: HEDIS Provider Toolkit

July 2017 Newsletter

MHC Provider Policies

Want to know what procedures require Prior Authorization? Need up-to-date information on commonly ordered drugs? Or, do you need to know which drugs require step therapy? Access this information on MHC’s Providers page under the Policies tab.

Access this information here: Provider Policies

Study Says ACA Market is Stabilizing

Contrary to what some claim, the Affordable Care Act is not in a death spiral, according to the Kaiser Foundation report, “Individual Insurance Market Performance in Early 2017.” While Kaiser’s earlier analysis of premium and claims data from 2011 to 2016 found insurers’ financial performance indeed worsened in 2014 and 2015 with the opening of the exchange markets, their performance showed signs of improving in 2016. The most recent analysis of insurers’ first-quarter financial data is even more positive.

Read the article here: Study Says ACA Market is Stabilizing

Zika Virus

Zika virus spreads to people primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus), but can also be spread during sex by a person infected with Zika to his or her sex partners.  Many people infected with Zika won’t have symptoms, but for those who do, the illness is usually mild with symptoms lasting from several days to a week. The most common symptoms of Zika are fever, rash, joint pain, and conjunctivitis (red eyes). Severe disease requiring hospitalization is uncommon. However, Zika infection during pregnancy can cause a serious birth defect of the brain called microcephaly and other severe fetal brain defects. Until more is known, CDC recommends that pregnant women avoid traveling to areas with Zika.

Click here to learn more about transmission during sex.  Click here for more information on microcephaly.


June 2017 Newsletter

MHC Adopts CDC Opioid Treatment Guidelines

MHC has adopted the clinical practice guideline (CPG) established by the CDC, released in 2016: Guideline for Prescribing Opioids for Chronic Pain. The guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care. The guideline addresses when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up and discontinuation; assessing risk and addressing harms of opioid use.

Please review by clicking here: CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

HHS Announces More Than $70 Million in Grants to Address the Opioid Crisis

Health and Human Services Secretary Tom Price, M.D., announced the availability of over $70 million over multiple years to help communities and healthcare providers prevent opioid overdose deaths and provide treatment for opioid use disorder, of which $28 million will be dedicated for medication-assisted treatment (MAT).

Provider Resources, click to view: HHS Opioid Crisis Announcement

Be Prepared – Extreme Heat Information and Tools

As we head into the summer months, this is just a reminder of getting the word out regarding planning for and responding to periods of extreme heat including potential power outages.  It is a time to prepare yourself.  Whether you provide programs and services for an older adult, an individual with a disability or family caregivers, you know that each person’s needs and abilities are unique.  Every individual can take important steps to prepare for periods of extreme heat including risk for potential power outages and put plans in place. By evaluating needs and making emergency plans, everyone can be better prepared for any situation.

A Commitment to planning today will help you prepare your consumers for extreme heat situations including risk for power outages.  The following are just a few examples of information and tools that are available online to help you prepare for and respond to extreme heat:

 For more information, click here:

May 2017 Newsletter

National Stroke Awareness Month and National High Blood Pressure Education Month

May is National Stroke Awareness Month and National High Blood Pressure Education Month. MHC is promoting the Million Hearts® campaign in encouraging our members to understand the risk factors associated with stroke. As a provider, you can help your patients take their blood pressure medicine as prescribed using this information. The CDC provides resources to empower Americans to manage risk factors—like high blood pressure—that contribute to stroke and encourage people to learn the signs and symptoms of stroke.

Click here to take the Quiz: Can You Spot the Signs and Symptoms of a Stroke?

Click here for provider resources: Help Patients Take Blood Pressure Medicine as Directed

Improving Health Care Quality

MHC attained NCQA accreditation in 2015 and is preparing now for our 2018 renewal survey. Providers are important partners in this process as numerous studies have provided compelling evidence that investing in employees’ health pays off measurably. In fact, between 50,657 and 186,572 deaths could be prevented each year if all U.S. health plans delivered the same quality of care as the nation’s top plans reporting HEDIS data to NCQA. Providing information during our Medical Record Review (MRR) process helps MHC to improve our health plan offerings to our members.

No Tobacco Day – May 31st

The Centers for Disease Control (CDC) in conjunction with the World Health Organization (WHO) have designated Wednesday, May 31st as No Tobacco Day to promote health living and smoking cessation. Consider discussing these items with your patients and download these smoking facts from your state:

  • Smoking leads to disease and disability and harms nearly every organ of the body
  • Smoking is the leading cause of preventable death
  • The tobacco industry spends billions of dollars each year on cigarette advertising
  • Smoking costs the United States billions of dollars each year
  • 15.1% of all adults (36.5 million people): 16.7% of males, 13.6% of females were current cigarette smokers in 2015
  • Thousands of young people start smoking cigarettes every day
  • Many adult cigarette smokers want to quit smoking

Click here for more information :Montana Smoking Facts

March 2017 Newsletter

HEDIS 2017 and Inovalon

Once again it is the season to measure performance on MHC member’s care and service. HEDIS® – the Healthcare Effectiveness Data and Information Set is a performance measurement tool used to demonstrate the quality care that MHC and other health providers obtain for our members and patients. MHC staff or our contracted representatives from Inovalon may contact you soon to collect medical record information for your patients who are MHC members.

 Why we do this

HEDIS® data collection is a nationwide, joint effort among employers, health plans and physicians. The goal is to monitor and compare health plan performance as specified by the National Committee for Quality Assurance (NCQA), the registered owner of HEDIS®.

In addition, MHC is required to send health care quality data to the Centers for Medicare & Medicaid Services (CMS). We collect most of the data from claims and patient encounters. We also gather data on provided services and health status from our members’ medical records.

 What we may need from you

If MHC or Inovalon contacts you, we ask that you provide timely access to our members’ medical records. Our contracted representatives will work with you and give you options for submission of the medical records.

Meeting HIPAA guidelines

Inovalon serves MHC in a role that the Health Insurance Portability and Accountability Act (HIPAA) defines and covers. HIPAA defines MHC as a Covered Entity and Inovalon’s role as a Business Associate of a Covered Entity. Providing medical record information to us or our contracted representatives is allowed under HIPAA regulations.


University of Utah Health Plans: New MHC Plan Administrator 2018

We are pleased to announce that beginning in 2018, MHC will be utilizing the University of Utah Health Plans as our new plan administrator.  U of U Health Plans will assume many of the same services that have been provided by Altius/Aetna since MHC’s inception.

U of U Health Plans has an outstanding reputation as a third-party administrator, and promises to function as a responsive and cost-efficient partner to MHC.  Offering great value, our collaboration with U of U Health Plans promises an increased focus on innovation and quality while bringing an expanded range of care options to MHC members and providers.

During 2017, MHC will be working to transition our policies and functions to U of U Health Plans.  This includes both re-credentialing and re-contracting, processes we have already initiated via a contract amendment sent by mail to our provider cadre.

We request your timely help in returning the signed agreement to MHC as soon as possible.

Our New Partner: University of Utah Health Plans

U of U Health Plans was founded in 1998 as a strategic initiative of University of Utah Health Care.  It currently serves over 167,000 members specializing in the health plan administration of medical, mental health and pharmacy benefits.

We are excited to offer U of U Health Plans extensive benefits to MHC members and providers beginning in 2018:

Health Plan Services:

Online Reporting Claims Administration Interpreting Services
MyChart + Member Portal Enrollment & Premium Processing Provider Portal
ID Cards + Phone App Subrogation Appeals
Access Assistance Phone Line “One Call” Resolution HIPAA


Health Care Management:

Data Share & Transparency Admissions & Concurrent Review Physician Led
Utilization Review Population Management Care Management
Pharmacy Management U Baby Maternity Program Disease Management
Risk Stratification 24/7 Nurse Line Large Case Management


For more information, please visit University of Utah Health Plans online:

June 2016 Newsletter

Help us collect HEDIS®* data

Our staff or our contracted representatives from Inovalon or HealthPort may soon contact you to collect medical record information for your patients who are MHC members.

Why we do this

Healthcare Effectiveness Data and Information Set (HEDIS)* data collection is a nationwide, joint effort among employers, health plans and physicians. The goal is to monitor and compare health plan performance as specified by the National Committee for Quality Assurance (NCQA)**.

We are required to regularly send health care quality data to the Centers for Medicare & Medicaid Services. We collect most of the data from claims and encounters. We also gather data on provided services and health status from our members’ medical records.

What we may need from you

If we contact you, we ask that you provide timely access to our members’ medical records. Our contracted representatives will work with you and give you options for sending the medical records.

Meeting HIPAA guidelines

Our representatives serve us in a role that the Health Insurance Portability and Accountability Act (HIPAA) defines and covers. As HIPAA defines, MHC is a “Covered Entity” and our representative’s role is as a “Business Associate of a Covered Entity.” Giving medical record information to us or our contracted representatives meets HIPAA regulations.

* HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

**NCQA is the National Committee for Quality Assurance.

Refer patients to our Complex Case Management program

Patients with complex cases often need extra help understanding their health care choices and benefits. They may also need support navigating the community services and resources available to them.

Our Complex Case Management program is a collaborative process that involves the member, his or her provider and MHC. The program aims to produce better health outcomes while efficiently managing health care costs.

A provider referral is one way members can gain access to the program. To make a referral, call the phone number on the member’s ID card. Our Case Management staff will call the member, explain the program and request permission for enrollment.

Disease management programs target chronic conditions

Our disease management programs for Asthma and Diabetes provide educational materials and, in some cases, individualized care management for members with chronic health conditions.

The programs help members with self-management of their disease by helping them better understand their condition and their doctor-prescribed treatment plan. The programs also educate members to accept the lifestyle changes that can help them achieve their optimal health status.

To enroll a member in a disease management program, call the phone number on the back of the member’s ID card.

Follow guidelines for appropriate lab testing

Your influence is crucial in helping members get recommended lab tests. We want to remind you of the evidence-based recommendations for annual lab testing for patients who are prescribed certain categories of medication.

Here are recommended lab tests for each medication category1:

Medication category Annual lab test(s)
Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) Serum potassium and serum creatinine or Serum potassium and blood urea nitrogen
Digoxin Serum potassium and serum creatinine or Serum potassium and blood urea nitrogen
Diuretics Serum potassium and serum creatinine or Serum potassium and blood urea nitrogen
Anticonvulsants Serum concentration for the prescribed drug
Be aware of premium grace period for exchange members

Members who buy insurance on a public exchange may qualify for a subsidy to help pay for their coverage. Subsidized members have different grace period rules as outlined below.

Members who receive a tax credit

Once these members pay at least one full month’s premium, they qualify for a three-month grace period. This means if the member can’t pay their monthly premium the month it is due, the member has three months from the due date to pay for coverage.  To keep their coverage, members must pay all the premium that is owed. If the member has not paid for all the premium owed in that 90-day period, we will cancel coverage.

How the grace period affects our payment to you for services:

  • We will pay providers for services the member receives during the first month of the grace period.
  • We will pend claims for services the member receives in the second and third months of the grace period.
  • If we don’t receive full payment by the end of the third month and we terminate the member’s coverage retroactively to the end of the first month of grace period, we won’t pay any pended claims. However, if the member pays in full prior to the end of grace period, all claims will then be processed. If the member is terminated for non-payment, you will need to bill the patient directly for those services we did not cover.


Verify eligibility for all patients

For a member who hasn’t paid his or her monthly premium, providers will receive a Remittance Advice (RA) indicating the claim was pended. This will occur for all claims received during the second and third months of the grace period.

Information about our quality management program

Our Quality Management Program helps improve the quality and safety of the health care your patients receive. Details on the program, its goals and our progress toward those goals are on our Commitment to Quality page or click this link to view our Quality Program.

Commercial Risk Adjustment Program

MHC from time to time will be requesting medical records to review and ensure proper diagnoses have been reported for our members. We also may have a vendor like CIOX (formerly Healthport and IOD) be requesting the information.


The objective of this program is to identify patients of individual or small group plans either on or off the health insurance exchange who currently have or are at risk for acute and chronic conditions. The goal is to help manage patient care through proper medical record documentation, coding and billing.

To help these efforts, you can:

  • Schedule health assessments for your MHC patients.
    • Provide medical records to our staff and/or our vendors: CIOX (formerly Healthport and IOD)
  • Evaluate health conditions and document them in medical records and claims


Medical record requests

Our vendors will retrieve records on our behalf, so submit them upon request. It helps identify patients with documented medical conditions that qualify for risk adjustment.

Improve your documentation

Remember to evaluate and document the treatment of all conditions at each encounter for each date of service.

Utilization Management Policy Updates

To make utilization management decisions, we use evidence-based clinical guidelines from nationally recognized authorities. Specifically, we review any request for coverage to determine if members are eligible for benefits, and if the service they request is a covered benefit under their plan. We also determine if the service delivered is consistent with established guidelines.


We don’t reward practitioners or employees for issuing denials of coverage or creating barriers to care or service. Financial incentives for UM decision makers don’t encourage decisions that result in underutilization.


To learn more about our Utilization Management Program operated by Aetna please visit this link.

Pharmacy Formulary

At least annually, and from time to time throughout the year, we update our formulary for Pharmacy Preferred Drug Lists. These drug lists are also known as our formularies. To find them, please click here.

If you need assistance with a member pharmacy prescription issue, please call our Pharmacy Management Provider Help Line at 855 488 0621.

Consult Clinical Practice Guidelines and Preventive Service Guidelines as you care for patients

The National Committee for Quality Assurance (NCQA) requires health plans to regularly let providers know about the availability of Clinical Practice Guidelines (CPGs). MHC utilizes Aetna’s CPGs and Preventive Service Guidelines (PSGs) which are based on nationally recognized recommendations and peer-reviewed medical literature. You’ll find them on our website or click here.

From this landing page, you can follow the links to:

Medical Clinical Policy Bulletins
Dental Clinical Policy Bulletins
Pharmacy Clinical Policy Bulletins
Clinical Policy Bulletins FAQs

Follow-up appointments post-hospitalization — coordination between hospitals and outpatient providers

According to National Institute of Mental Health studies, mental health disorders are a leading cause of disability* that affect nearly 60 million adults** and cost more than $300 billion annually***. Proper follow-up care can improve health outcomes for adults and children.


NCQA HEDIS® measure follow-up care for mental health diagnoses.  HEDIS is a long-standing industry tool used to measure performance on a wide range of health care domains. One measure looks at the percentage of discharges for patients hospitalized for mental health treatment and had an outpatient, IOP or partial hospitalization visit post discharge. Two rates are reported:


  • Percentage of inpatient discharges where the patient received follow-up within 7 days of discharge
  • Percentage of inpatient discharges where the patient received follow-up within 30 days of discharge


Why 7 day follow-up?

Effective follow-up care after discharge from a psychiatric hospitalization is vital. It can help reduce the risk of suicide, decrease repeat hospitalizations and identify patients in need of more interventions before they reach a crisis point.


Here are a few things you can do to increase follow-up care:

  • Plan for the discharge from the onset of services
  • Communicate the importance of follow-up care to patients and their support network
  • Schedule the outpatient appointment prior to discharge and include the appointment information on the

discharge instructions


These resources can help:

  • National Quality Measures Clearinghouse
  • Articles on the suicide and readmission risk of patients discharged from an inpatient mental health stay
  • Hospital tools for discharge planning


National Committee for Quality Assurance (NCQA) is a private, non-profit organization dedicated to improving health care quality.

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to provide

purchasers and consumers with the information they need to reliably compare the performance of health care plans.

* National Institute of Mental Health: Leading Categories of Diseases/Disorders. (29 July 2010) “Burden of Disease: Lead Contributing

Disease Categories to DALYs.” Retrieved from

** National Institute of Mental Health: Use of Mental Health Services and Treatment Among Adults. (29 July 2010) “Service Use/

Treatment of Serious Mental Illness Among U.S. Adults by Age and Type of Care (2008).” Retrieved from

*** National Institute of Mental Health: Annual Total Direct and Indirect Costs of Serious Mental Illness (2002). (29 July 2010) “Annual Total

Direct and Indirect Costs of Serious Mental Illness (2002) Retrieved from the National Institute of Mental Health.

Changing the story of mental health in America

As part of being a partner with Aetna, Aetna is playing a strong role in changing the story of mental health in America. MHC is grateful that Aetna can help our members and providers play a role in this too.


As part of Aetna’s ongoing collaboration with the non-profit organization, Give an Hour, we’re now supporting The Campaign to Change Direction ignited by Give an Hour. The campaign urges all Americans to learn the five signs that someone may be struggling with mental health concerns:

  • Their personality changes
  • They seem uncharacteristically angry, agitated or moody
  • They withdraw from others
  • They stop taking care of themselves
  • They seem overcome with hopelessness


How you can help

As a behavioral health care practitioner, your frontline support can make a difference to this effort and in the lives of your patients. You can:

  • Share the five signs through your practice
  • Take the pledge to increase mental health awareness
  • Visit the Change Direction website to learn more about

the campaign


How the campaign is working to eradicate mental health stigma

We’re proud to be a founding member of this national movement designed to change the story of mental health in America. At the launch in March of last year, First Lady Michelle Obama delivered the keynote address about the importance of changing the story on mental health. Louise Murphy, Head

of Aetna Behavioral Health, served as a panelist at this event.

Get paid faster by submitting all of your claims electronically

Submitting all of your MHC claims electronically means you’ll receive payments faster. Don’t have billing software?

 Register for our free secure provider website on and start submitting your professional claims for free!

 See how much you can save by doing all business with us electronically

Doing business with us electronically means more than just sending us your claims electronically. You can also check your patients’ eligibility and request precertification online. When you send us electronic transactions, it saves you time and money. Try our Provider Electronic Savings Calculator to

see how much you can save by doing all of your business with us electronically!

HEDIS® highlight: Initiation and Engagement of Alcohol and other Drug Dependence Treatment

As part of our ongoing efforts to support best practices and identify opportunities for improvement, we’re highlighting different HEDIS©1 quality-of-care behavioral health measures. This time we’re focusing on the Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) measure.


Alcohol and other drug (AOD) dependence is common across many age groups and is one of the most preventable of health

conditions. Abuse of and addiction to alcohol, nicotine, and illicit, and prescription drugs cost Americans more than $700 billion a year in increased health care costs, crime, and lost productivity.2 ,3 Every year, illicit and prescription drugs and alcohol contribute to the death of more than 90,000 Americans.4

The IET measure monitors whether adolescents and adults with an episode of AOD dependence had inpatient or outpatient treatment within 14 days of their initial diagnosis and two additional treatment visits within 30 days of the first visit.


How you can help

When giving a diagnosis of alcohol or other drug dependence, be sure to set up follow-up visits over the

next four to six weeks or refer the patient immediately to a behavioral health provider. For example:

  • Every time a patient receives a primary or secondary diagnosis indicating abuse of alcohol or other drugs, schedule a follow-up visit within 14 days.
  • During the second visit, schedule two additional visits and/or schedule the patient to see a substance abuse treatment specialist within the next 14 days.
  • Following a hospital discharge for a patient with an alcohol or other drug dependence diagnosis schedule two additional visits within 30 days.
  • Involve others who are supportive of the patient to increase participation in treatment.
  • Listen for and work with existing motivation in your patients.


Resources to help with screening and intervention


  • Alcohol Screening, Brief Intervention and Referral to Treatment Program
  • Screening instrument: The Alcohol Use Disorders Identification Test (AUDIT)5 — Available in English and in Spanish
  • Substance Abuse Screening for Adolescents with Depression and/or Anxiety

–This program helps adolescents suffering from depression and anxiety disorders by working with providers to identify early signs of drug and alcohol abuse, provide a plan for support and treatment, coordinate care and link to community and web-based resources.

  • Medication-Assisted Treatment for Alcohol and Substance Abuse

To find out more or refer an MHC member, just call the number on the back of the member’s ID card.

1 The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to provide purchasers and consumers with the information they need to reliably compare the performance of health plans.

2 National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society. Washington, DC: United States Department of Justice, 2011.

3Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 373(9682):2223-2233, 2009.

4Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC. Available at (August 2015).

5The AUDIT tool is a free written screening instrument provided in “Helping Patients Who Drink Too Much:A Clinician’s Guide.”

Check out new behavioral health CEs on our education site

As part of MHC having our excellent partner TPA Aetna, you have access to Aetna’s education site for health care professionals, a no-cost single source of learning opportunities for providers.

Check out these new behavioral health continuing education (CE) programs at

  • Adherence to Prescription Medication
  • Eating Disorders and Treatment Updates
  • Psychopharmacology
  • Federal Mental Health Parity & Addiction Equity Act – A Compliance Overview for Clinicians
  • Technologies for post-traumatic stress problems: Assisting veterans and others with PTSD
  • Understanding Mental Illness: What Individuals and Families Living with the Illnesses Want Professionals to Know
Provider Manuals include information about patient rights

Our Office Manual for Health Care Professionals and our Behavioral Health Provider Manual available on our public website at They include information on member rights and responsibilities and nondiscrimination.


All participating physicians and behavioral health practitioners should have a documented non-discrimination policy. Federal and state laws prohibit discrimination in the treatment of patients on the basis of race, ethnicity, national origin, religion, sex, age, mental or physical disability, medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information or source of payment.

Patient rights under ADA

All participating physicians, behavioral health practitioners and health care professionals may also have an obligation under the Federal Americans with Disabilities Act (ADA) to provide physical access to their offices and reasonable accommodations for patients and employees with disabilities. If you don’t have Internet access, call our Provider Service Center for a paper copy of these manuals.

April 2016 Newsletter

NCQA Standards

The National Committee for Quality Assurance (NCQA) requires health plans to regularly let providers know about the availability of Clinical Practice Guidelines (CPGs) and other quality standards.

Information on these policies is available to providers here.

MHC's Commitment to Quality Improvement

Montana Health CO-OP is committed to helping improve the quality and safety of healthcare. We’re working hard to ensure that our practices enhance and improve the health of our members.

You can read more about our quality goals and expected outcomes here.

Inovlan and Quality

MHC is working with Inovlan, a company that provides healthcare quality and care management services to more than 200 healthcare organizations and their members nationwide. We have contracted with Inovalon for their data mining and analytics to help us ensure quality care.

Inovalon will be randomly selecting members from providers. Providers will be contacted in regards to SOAP notes, and will be asked to provide patient information in Inovlan format. Providers will be incentivized to supply this information.

Provider Forum 2015

Provider Forum 2015 sessions are underway throughout the state.