Medicaid & Healthy Montana Kids Plus
Health Improvement Program Provider Referral Form


The Health Improvement Program (HIP) serves Medicaid and HMK Plus patients with chronic illnesses or risks of developing serious health conditions. HIP service providers are Community and Tribal Health Centers. Click this link to see a map of the providers.

Patients who are eligible for Passport are enrolled and assigned to a health center for possible care management. Your current Passport patients will stay with you for their primary care, but are eligible for care management through one of the participating health centers. Nurses and health coaches certified in Professional Chronic Care will

  • conduct health assessments
  • work with you to develop care plans
  • educate patients in self management and prevention
  • provide pre and post hospital discharge planning
  • help with local resources
  • and remind patients about scheduling needed screening and medical visits

Montana uses predictive modeling software to identify chronically ill patients. This software uses medical claims, pharmacy and demographic information to generate a risk score for each person. Although the software will provide a great deal of information for interventions, it will not identify patients who have not received a diagnosis or generated claims. If you have Passport patients at high risk for chronic health conditions that would benefit from case management, please complete the following form.

Required fields are marked with *