Provider Bulletin

Independent Medical Evaluations (IME’s)

IME: Montana State Fund has been using 99499 for a number of years to indicate Independent Medical Evaluation (IME) services that are provided by non-contracted physicians.  99499 should only be used for IME services and Psychological Pre-surgical evaluations.

99499 is officially an unlisted Evaluation and Management code, however, MSF requires IME service providers use this code for non-contracted providers. This allows MSF capture IME costs as there is no actual code for those services.

Impairment Rating: If an impairment Rating (IR) is completed later as part of an IME due to the injured worker not being at Maximum Medical Improvement or after review of other diagnostics being done prior to calculating a rating should also be billed as 99499.

If only an IR is being requested and it is not part of an IME, then 99455 or 99456 should be used.
99455 – Work related or medical disability examination by the treating physician that includes:  Completion of a medical history commensurate with the patient’s condition, performance of an examination commensurate with the patient’s condition, formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment, development of future medical treatment plan and completion of necessary documentation/certificates and report.

99456 – Work related or medical disability examination by the other than the treating physician that includes:  Completion of a medical history commensurate with the patient’s condition, performance of an examination commensurate with the patient’s condition, formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment, development of future medical treatment plan and completion of necessary documentation/certificates and report.

The impairment calculation must be done per the 6th edition of the Guides to Evaluation of Permanent Impairment (published by the American Medical Association) with the 6th Edition being noted as well as the calculation and any of the related documentation attached.

NOTE:  If an impairment ONLY is being requested, please bill using the impairment rating code.  Do NOT bill using the IME code.  These bills will be denied for incorrect procedure code.

Psychological Pre-Surgical Evaluation: Psychological pre-surgical evaluations must be billed using 99499.  For all other psychological services, please use the actual psychological service codes.

IME Review: If a request has been sent to a provider to review an IME done by another provider, it must be billed using MT001 with total time spent documented in the note.  This code is paid per fee schedule.  These requests are usually accompanied by a list of question from the Claim Examiner.

Travel/Mileage: Travel/mileage are paid using the State of Montana Travel Policy and is billed using A9200.   A separate line should be used for each segment of travel (ie; mileage or airfare, hotel, etc.) If seeing more than 1 injured worker/patient, these charges must be divided by the number of injured workers/patients seen for that trip and the result billed for each injured worker/patient seen.  If you have further questions, please call the Medical Team at the number listed in this Bulletin.

Bill Status – 1-877-591-8028

Main Phone Number 406-495-5000 or 800-332-6102

Main Fax  406-495-5020

Medical Team – 406-495-5011

Submit your Claims and/or Correspondence To
Montana State Fund
PO Box 4759
Helena, MT  59604

ACS (Bill Status)
Phone  888-208-2116
Email  BillReviewInquiries

For questions regarding
: Information in this bulletin, call 800-332-6102 and ask for a member of the Medical Team. Advanced Nurse Review, Kym Vonada at 406-495-5389.


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Heather O’Hara
Nurse Manager
406-495-5458

Justin Kennedy
Medical Management Specialist
406-495-5417

Shannon Hadley
Provider Relations Specialist
406-495-5245

Kym Vonada
Medical Auditor
406-495-5389

Annalyn Stewart
Medical Payment Auditor
406-495-5367

Susan Bomar
Medical Payment Auditor
406-495-5271

Cindy Gallus
Medical Customer Service Liaison
406-495-5189

Sherri Sprenger
Medical Customer Service Liaison
406-495-5420

Shannon Mergenthaler
Medical Customer Service Liaison
406-495-5185

Maggie Pentecost
Medical Customer Service Liaison
406-495-5322

Jamie Statton
Medical Customer Service Liaison
406-495-5386

Website Information

Montana State Fund montanastatefund.com

Department of LaborDepartment of Labor and Industry (DLI) website.
The website includes the Facility and Non-Facility Fee Schedule information as well as the Administrative Rules of Montana (ARM) and the instruction set for the Non-Facility Fee Schedule. Historical fee schedule information can also be found on this website.

If you have questions regarding the fee schedules call 406-444-6530 and someone will direct you to a DLI representative. For NPI information click here National Plan and Provider Enumeration System (NPPES)