Provider Connection

Utilization and Treatment Guidelines

nurseLegislative Updates

Utilization and Treatment Guidelines

The Montana Department of Labor & Industry (DLI) held a hearing June 6, 2011, to adopt the Utilization & Treatment Guidelines (Montana Utilization and Treatment Guideline, 1st Edition, 2011) and medical services rules. U&T Guidelines were passed as part of House Bill 738 in the 2007 legislative session and the draft form may be found at http://www.mtguidelines.com.

The U&T Guidelines will take effect July 1, 2011, and will change the way treatment is provided within workers’ compensation. Some of the highlights are:

  • The Montana U&T Guidelines are based on Colorado’s U&T Guidelines and the Official Disability Guidelines of the American College of Occupational and Environmental Medicine (ACOEM).
  • Prior authorization process changes based on U&T Guidelines. Prior authorization will only be required when:
    • The treatment(s) or procedure(s) is not specifically addressed or recommended by the U&T Guidelines for a body part that is covered by a guideline,
    • After maximum medical improvement, or
    • Beyond the duration and frequency limits set out in the guidelines.
  • A medical advisor will be employed by DLI to:
    • Monitor new procedures and technologies.
    • Consult with health care providers with relevant experience and education.
    • Provide an annual review of the evidence-based Utilization and Treatment Guidelines.
    • Review requests for any treatment(s) or procedure(s) that is not specifically addressed or recommended by the U&T Guidelines, when those requests have been initially denied.
  • There are two types of medical services within the U&T Guidelines: primary and secondary.
    • Per MCA 39-71-116 – primary medical services means treatment prescribed by a treating physician, for conditions resulting from the injury, necessary to achieving medical stability.
    • Per MCA 39-71-116 – secondary medical services are those medical services or appliances that are considered not medically necessary for medical stability.
  • The U&T Guidelines will include nine chapters:
    • Low Back Pain
    • Lower Extremity
    • Shoulder Injury
    • Upper Extremity
    • Chronic Region Pain Syndrome
    • Cervical Spine Injury
    • Chronic Pain Disorder
    • Traumatic Brain Injury
    • Eye Injury

Please see the DLI website for complete information regarding the U&T Guidelines at http://dli.mt.gov.

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Bill Status – 1-866-274-7464

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

RMS (Bill Status)
Phone  866-274-7464
Email customer.care@risingms.com

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


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Justin Kennedy
Nurse Manager
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

Sheryl Semans
Pharmacy Liaison
406-495-5010

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)