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Indian Health Services/Tribal 638

Indian Health Services/Tribal 638 Manual

Indian Health Services/Tribal 638 Manual

Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

If you experience any difficulty opening a section or link from this page, please email the webmaster.

How to Search this manual:

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.
  2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

Prior manuals may be located through the provider website archives.

 


Indian Health Services/Tribal 638 Manual

Updated 08/15/2017

This manual was updated 08/15/2017

Update Log

Update Log

 

Publication History

This publication supersedes all previous Medicaid Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.

Updated April 2013, July 2013, February 2014, June 2014, July 2015, August 2016 and August 2017.

CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Update Log

08/15/2017
Indian Health Services/Tribal 638 Manual converted to an HTML format and adapted to 508 Accessibility Standards.

08/08/2016
Indian Health Service, August 2016:
In Summary, the Cost Share section of the Billing Procedure Chapter was removed and replaced with a referral to the Cost Share section of the General Manual. The Cover Page was changed to reflect the current manual edition date.

07/01/2015
Indian Health Service, July 2015: Entire Manual

08/01/2014
Indian Health Service, June 2014: Billing Procedures

04/04/2014
Indian Health Service, February 2014: Multiple Chapters

08/29/2013
Indian Health Service, July 2013: Key Contacts and Billing Procedures

05/15/2013
Indian Health Service, April 2013: Entire Manual
This set of replacement pages includes the entire IHS manual. Content changes are indicated by the addition of a change bar (black line). Text in tables and paragraphs in which text was deleted are not indicated with change bars. For a complete manual without the change bars, see the Provider Manuals section at the top of this page.

 

End of Update Log Chapter

Table of Contents

Key Contacts

Key Contacts

 

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, http://medicaidprovider.mt.gov/, for a list of key contacts and websites.

DPHHS IHS Program

(406) 444-4540
(406) 444-1861 Fax

IHS Program Officer
Hospital and Physician Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Indian Health Service Area Office

Billings Area IHS Office
2900 4th Avenue North
Billings, MT 59101

(406) 247-7100 Main

Indian Health Service Units

Blackfeet Service Unit
Blackfeet Community Hospital
P.O. Box 760
Browning, MT 59417

(406) 338-6100 Main
(406) 338-2959 Fax

Heart Butte Health Station
P.O. Box 80
Heart Butte, MT 59448

(406) 338-2151 Main
(406) 338-5613 Fax

Crow Service Unit
Crow/Northern Cheyenne Hospital
P.O. Box 9
Crow Agency, MT 59022

(406) 638-3500 Main
(406) 638-3569 Fax

Lodge Grass Health Clinic
P.O. Box AD
Lodge Grass, MT 59050

(406) 639-2317 Main
(406) 639-2976 Fax

Pryor Health Station
P.O. Box 9
Pryor, MT 59066

(406) 259-8238 Main
(406) 259-8290 Fax

Fort Belknap Service Unit
Fort Belknap Hospital
669 Agency Main Street
Harlem, MT 59526

(406) 353-3100 Main
(406) 353-3227 Fax

Eagle Child Health Station
P.O. Box 610
Hays, MT 59527

(406) 673-3777 Main
(406) 673-3835 Fax

Fort Peck Service Unit
Chief Redstone Clinic
550 6th Avenue North
P.O. Box 729
Wolf Point, MT 59201

(406) 653-1641 Main

Verne E. Gibbs Clinic
107 H. Street
P.O. Box 67
Poplar, MT 59255

(406) 768-3491 Main

Northern Cheyenne Service Unit
Lame Deer Health Center
P.O. Box 70
Lame Deer, MT 59043

(406) 477-4400 Main
(406) 477-4427 Fax

Tribally Operated Health Programs

Flathead Tribal Health
P.O. Box 880
St. Ignatius, MT 59865

(406) 745-3525 Main

Rocky Boy Tribal Health
P.O. Box 664
Box Elder, MT 59521

(406) 395-4486 Main

Montana Tribal Nations

Blackfeet Nation
Blackfeet Tribal Business Council
Box 850
Browning, MT 59417

(406) 338-7521 Main
(406) 338-7530 Fax

Chippewa Cree Tribe
Chippewa Cree Business Committee
Rocky Boy Route 544
Rocky Boy Agency
Box Elder, MT 59521

(406) 395-5705 Main
(406) 395-5702 Fax

Confederated Salish and Kootenai Tribes
CSK Tribal Council
P.O. Box 278
Pablo, MT 59855

(406) 675-2700 Main
(406) 675-2806 Fax

Fort Belknap Tribes
Fort Belknap Indian Community Council
656 Agency Main Street
Harlem, MT 59526

(406) 353-2205 Main
(406) 353-4541 Fax

Fort Peck Tribes
Fort Peck Tribal Executive Board
P.O. Box 1027
Poplar, MT 59255

(406) 768-2300 Main
(406) 768-5478 Fax

Northern Cheyenne Tribe
Northern Cheyenne Tribal Council
P.O. Box 128
Lame Deer, MT 59043

(406) 477-6284 Main
(406) 477-6120 Fax

State Recognized Tribe
Little Shell Chippewa Tribe
625 Central Avenue West, Suite 100
Great Falls, MT 59403

(406) 452-2892 Main
(406) 452-2982 Fax

 

End of Key Contacts Chapter

Introduction

Introduction

 

Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for Indian Health Service (IHS)/tribal 638 providers who provide services to members who are eligible for both Medicaid and Indian Health Service. Other essential information for providers is contained in the separate General Information for Providers manual, available on the IHS page of the Provider Information website. Providers are asked to review both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.

Manual Maintenance

Manuals must be kept current.

Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type page of the provider website.  Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Rule References

Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us page on the Provider Information website.

Providers are responsible for knowing and following current Medicaid laws and regulations.

In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the Indian Health Service program:

  • Code of Federal Regulations (CFR)
    • 42 CFR Part 136 and 136A
  • Montana Codes Annotated (MCA)
    • MCA 53-6-101
  • Administrative Rules of Montana (ARM)
    • ARM 37.82.101

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. Medicaid manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.

 

End of Introduction Chapter

Covered Services

Covered Services

 

General Coverage Principles

This chapter provides covered services information that applies specifically to Indian Health Service (IHS)/tribal 638 providers who provide services to members who are eligible for both Medicaid and IHS. Like all healthcare services received by Medicaid members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Members of federally recognized Indian tribes and their descendants are eligible for services provided by IHS, an agency of the U.S. Public Health Service, Department of Health and Human Services.

Provider Requirements
IHS physicians must meet Montana Medicaid’s State Plan requirements. Physician requirements are available in the Physician-Related Services manual available on the Provider Information website. Montana Medicaid does not require IHS physicians to hold a Montana physician license; however, they must meet the substantive licensure requirements. The Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physician’s current license from another state would satisfy this requirement.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children age 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:

  • Nutritionist services
  • Private duty nursing
  • Respiratory therapy
  • Therapeutic family and group home care
  • Substance dependency inpatient and day treatment services
  • School-based services

All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers manual.

Coverage of Specific Services

Medicaid covers the same services for members who are enrolled in Medicaid and IHS as those members who are enrolled in Medicaid only. All requirements for Medicaid services (such as prior authorization, Passport and others) also apply to Medicaid enrolled members who qualify for IHS services.

Importance of Fee Schedules

The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (IHS/tribal 638 are provider type 57). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website.

 

End of Covered Services Chapter

Passport to Health Program

Passport to Health Program

 

What Is Passport to Health? (ARM 37.86.5101–5120)

Passport to Health is the managed care program for Montana Medicaid and Healthy Montana Kids (HMK) Plus members. The four Passport programs encourage and support Medicaid and HMK Plus members and providers in establishing a medical home and in ensuring the appropriate use of Medicaid and HMK Plus services:

  • Passport
  • Team Care
  • Nurse First Advice Line
  • Health Improvement Program

For more information regarding Passport to Health, see the Passport to Health manual available on the Provider Information website.

Passport and Indian Health Service

Members who are eligible for both Indian Health Service (IHS)/tribal 638 and Medicaid may choose an IHS/tribal 638 provider or another provider as their Passport provider. Members who are eligible for IHS do not need a referral from their Passport provider to obtain services from IHS. However, if IHS refers the member to a non-IHS provider, the Passport provider must provide the referral.

Passport information is found in the Passport to Health manual, available on the Provider Information website.

 

End of Passport to Health Program Chapter

Prior Authorization

Prior Authorization

 

Prior authorization refers to a list of services that require approval from the Medicaid program prior to the service being rendered. If a service requires prior authorization, the requirement exists for all Medicaid members. When prior authorization is granted, the provider is issued a prior authorization number, which must be included on the claim.

Medicaid does not pay for services when prior authorization requirements are not met. See the Prior Authorization Information link in the left menu on the Provider Information website.

 

End of Prior Authorization Chapter

Coordination of Benefits

Billing Procedures

Billing Procedures

 

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

See the General Information for Providers manual for additional information on member cost sharing.

IHS Revenue Codes

IHS providers may bill Medicaid with the revenue codes shown in the current fee schedule.

Billing for Specific Services

Prior authorization is required for some services. Passport and prior authorization are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers manual.)

Some services provided by an IHS are billed with the IHS provider number and codes specific to IHS. Other services require the IHS to enroll as a Medicaid provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the Medicaid provider number assigned to that provider type. All providers must be enrolled with Medicaid before billing for services.

Every claim for Medicaid services must indicate the provider of service. Claims for services rendered in IHS facilities are submitted using the IHS facility’s provider number. However, when services are rendered in a non-IHS facility, the claim should be submitted using the individual’s provider number.

IHS physicians do not receive reimbursement directly from Medicaid but from the IHS. IHS providers must show the Billings Area Indian Health Service as the “pay to” address on the enrollment form.

 

End of Billing Procedures Chapter

 

Remittance Advices and Adjustments

Remittance Advices and Adjustments

 

For information on remittance advices and adjustments, see the General Information for Providers manual, available on the website.

 

End of Remittance Advices and Adjustments Chapter

How Payment Is Calculated

How Payment Is Calculated

 

Overview

Though providers do not need the information in this chapter to submit claims to Montana Medicaid, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Montana Medicaid operates the IHS/tribal 638 facilities according to the Medicaid State Plan, which states that services provided by IHS/tribal 638 facilities are paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services for IHS as set forth in the Federal Register. Subsequent payment adjustments will be made pursuant to changes published in the Federal Register.

Section 1905(b) of the Social Security Act (the Act) provides that 100% Federal Medical Assistance Percentages (FMAP) is available to states for amounts spent on medical assistance received through an IHS facility whether operated by the IHS or by an Indian tribe or tribal organization, as defined in Sec. 4 of the Indian Health Care Improvement Act.

Physician services provided by IHS physicians in non-IHS facilities are not eligible for 100% federal funds, but rather at the regular federal/state match rate of approximately 65% federal funds and 35% state funds. Montana Medicaid pays for these physician services by utilizing the Medicare Resource-Based Relative Value Scale (RBRVS) with a Montana-specific conversion factor.

IHS Rates Established by CFR

IHS/tribal 638 facilities are paid in accordance with the most current Federal Register Notice, published by IHS and approved by CMS.

Services provided by facilities of the IHS, which include at the option of a tribe or tribal organization, services by tribal 638 facilities funded by Title I or Title V of the Indian Self-Determination and Education Assistance Act (P.L. 93-638), are paid at the rates negotiated between CMS and the IHS and published in the Federal Register.

Payment for IHS/tribal 638 inpatient hospital services is made in accordance with the inpatient hospital per diem rate published in the Federal Register by the IHS. Payment for IHS/tribal 638 outpatient services is made in accordance with the outpatient per-visit rate published by the IHS in the Federal Register.

 

End of How Payment is Calculated Chapter

Appendix A: Forms

Appendix A: Forms

 

The forms listed as examples below and others are found on the Forms page of the Provider Information website.

  • Individual Adjustment Request
  • Paperwork Attachment Cover Sheet

 

End of Appendix A: Forms Chapter

Definitions and Acronyms

Definitions and Acronyms

 

See the Definitions and Acronyms page of the Provider Information website for additional definitions and acronyms.

Date of Submission

The date the claim is stamped received by Montana Medicaid. A claim lost in the mail is not considered received.

Indian Health Service (IHS)

IHS provides health services to American Indians and Alaska Natives.

Indian Health Service (IHS) Facility

An IHS facility is an entity that is either owned or leased by the IHS of the Public Health Service. The IHS equates facilities that are leased by IHS to those that are owned by IHS for purposes of defining an IHS facility. IHS keeps a specific listing of its owned and leased facilities. Some IHS facilities, although owned by IHS, may be operated by a tribe or tribal organization.

Patient Day

An individual present and receiving medical services in a facility for a whole 24-hour period. Although an individual may not be present for a whole 24-hour period on the day of admission, such a day will be considered a patient day. The day of discharge will not be counted as a patient day except when the patient is admitted and discharged on the same day.

Tribal 638 Facility

A facility or location owned and operated by a federally recognized American Indian Tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

 

End of Definitions and Acronyms Chapter

Index

Index

Previous editions of this manual contained an index.

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.
  2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Index Chapter

End of Indian Health Services/Tribal 638 Manual

Complete Indian Health Services/Tribal 638 Manual

Complete Indian Health Services/Tribal 638 Manual

To print this manual, right click your mouse and choose "print".  Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

 

Update Log

 

Publication History

This publication supersedes all previous Medicaid Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.

Updated April 2013, July 2013, February 2014, June 2014, July 2015, August 2016 and August 2017.

CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Update Log

08/15/2017
Indian Health Services/Tribal 638 Manual converted to an HTML format and adapted to 508 Accessibility Standards.

08/08/2016
Indian Health Service, August 2016:
In Summary, the Cost Share section of the Billing Procedure Chapter was removed and replaced with a referral to the Cost Share section of the General Manual. The Cover Page was changed to reflect the current manual edition date.

07/01/2015
Indian Health Service, July 2015: Entire Manual

08/01/2014
Indian Health Service, June 2014: Billing Procedures

04/04/2014
Indian Health Service, February 2014: Multiple Chapters

08/29/2013
Indian Health Service, July 2013: Key Contacts and Billing Procedures

05/15/2013
Indian Health Service, April 2013: Entire Manual
This set of replacement pages includes the entire IHS manual. Content changes are indicated by the addition of a change bar (black line). Text in tables and paragraphs in which text was deleted are not indicated with change bars. For a complete manual without the change bars, see the Provider Manuals section at the top of this page.

 

End of Update Log Chapter

 

Table of Contents

 

Key Contacts

Introduction

Manual Organization

Manual Maintenance

Rule References

Claims Review (MCA 53-6-111, ARM 37.85.406)

Getting Questions Answered

Covered Services

General Coverage Principles

  • Provider Requirements
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)

Coverage of Specific Services

Importance of Fee Schedules

Passport to Health Program

What Is Passport to Health? (ARM 37.86.5101–5120)

Passport and Indian Health Service

Prior Authorization

Coordination of Benefits

Billing Procedures

Claim Forms

Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)

IHS Revenue Codes

Billing for Specific Services

Remittance Advices and Adjustments

How Payment Is Calculated

Overview

IHS Rates Established by CFR

Appendix A: Forms

Definitions and Acronyms

Index

 

End of Table of Contents Chapter

 

Key Contacts

 

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website, http://medicaidprovider.mt.gov/, for a list of key contacts and websites.

DPHHS IHS Program

(406) 444-4540
(406) 444-1861 Fax

IHS Program Officer
Hospital and Physician Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Indian Health Service Area Office

Billings Area IHS Office
2900 4th Avenue North
Billings, MT 59101

(406) 247-7100 Main

Indian Health Service Units

Blackfeet Service Unit
Blackfeet Community Hospital
P.O. Box 760
Browning, MT 59417

(406) 338-6100 Main
(406) 338-2959 Fax

Heart Butte Health Station
P.O. Box 80
Heart Butte, MT 59448

(406) 338-2151 Main
(406) 338-5613 Fax

Crow Service Unit
Crow/Northern Cheyenne Hospital
P.O. Box 9
Crow Agency, MT 59022

(406) 638-3500 Main
(406) 638-3569 Fax

Lodge Grass Health Clinic
P.O. Box AD
Lodge Grass, MT 59050

(406) 639-2317 Main
(406) 639-2976 Fax

Pryor Health Station
P.O. Box 9
Pryor, MT 59066

(406) 259-8238 Main
(406) 259-8290 Fax

Fort Belknap Service Unit
Fort Belknap Hospital
669 Agency Main Street
Harlem, MT 59526

(406) 353-3100 Main
(406) 353-3227 Fax

Eagle Child Health Station
P.O. Box 610
Hays, MT 59527

(406) 673-3777 Main
(406) 673-3835 Fax

Fort Peck Service Unit
Chief Redstone Clinic
550 6th Avenue North
P.O. Box 729
Wolf Point, MT 59201

(406) 653-1641 Main

Verne E. Gibbs Clinic
107 H. Street
P.O. Box 67
Poplar, MT 59255

(406) 768-3491 Main

Northern Cheyenne Service Unit
Lame Deer Health Center
P.O. Box 70
Lame Deer, MT 59043

(406) 477-4400 Main
(406) 477-4427 Fax

Tribally Operated Health Programs

Flathead Tribal Health
P.O. Box 880
St. Ignatius, MT 59865

(406) 745-3525 Main

Rocky Boy Tribal Health
P.O. Box 664
Box Elder, MT 59521

(406) 395-4486 Main

Montana Tribal Nations

Blackfeet Nation
Blackfeet Tribal Business Council
Box 850
Browning, MT 59417

(406) 338-7521 Main
(406) 338-7530 Fax

Chippewa Cree Tribe
Chippewa Cree Business Committee
Rocky Boy Route 544
Rocky Boy Agency
Box Elder, MT 59521

(406) 395-5705 Main
(406) 395-5702 Fax

Confederated Salish and Kootenai Tribes
CSK Tribal Council
P.O. Box 278
Pablo, MT 59855

(406) 675-2700 Main
(406) 675-2806 Fax

Fort Belknap Tribes
Fort Belknap Indian Community Council
656 Agency Main Street
Harlem, MT 59526

(406) 353-2205 Main
(406) 353-4541 Fax

Fort Peck Tribes
Fort Peck Tribal Executive Board
P.O. Box 1027
Poplar, MT 59255

(406) 768-2300 Main
(406) 768-5478 Fax

Northern Cheyenne Tribe
Northern Cheyenne Tribal Council
P.O. Box 128
Lame Deer, MT 59043

(406) 477-6284 Main
(406) 477-6120 Fax

State Recognized Tribe
Little Shell Chippewa Tribe
625 Central Avenue West, Suite 100
Great Falls, MT 59403

(406) 452-2892 Main
(406) 452-2982 Fax

 

End of Key Contacts Chapter

 

Introduction

 

Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for Indian Health Service (IHS)/tribal 638 providers who provide services to members who are eligible for both Medicaid and Indian Health Service. Other essential information for providers is contained in the separate General Information for Providers manual, available on the IHS page of the Provider Information website. Providers are asked to review both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.

Manual Maintenance

Manuals must be kept current.

Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type page of the provider website.  Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Rule References

Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us page on the Provider Information website.

Providers are responsible for knowing and following current Medicaid laws and regulations.

In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the Indian Health Service program:

  • Code of Federal Regulations (CFR)
    • 42 CFR Part 136 and 136A
  • Montana Codes Annotated (MCA)
    • MCA 53-6-101
  • Administrative Rules of Montana (ARM)
    • ARM 37.82.101

Claims Review (MCA 53-6-111, ARM 37.85.406)

The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. Medicaid manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.

 

End of Introduction Chapter

 

Covered Services

 

General Coverage Principles

This chapter provides covered services information that applies specifically to Indian Health Service (IHS)/tribal 638 providers who provide services to members who are eligible for both Medicaid and IHS. Like all healthcare services received by Medicaid members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Members of federally recognized Indian tribes and their descendants are eligible for services provided by IHS, an agency of the U.S. Public Health Service, Department of Health and Human Services.

Provider Requirements
IHS physicians must meet Montana Medicaid’s State Plan requirements. Physician requirements are available in the Physician-Related Services manual available on the Provider Information website. Montana Medicaid does not require IHS physicians to hold a Montana physician license; however, they must meet the substantive licensure requirements. The Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physician’s current license from another state would satisfy this requirement.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children age 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:

  • Nutritionist services
  • Private duty nursing
  • Respiratory therapy
  • Therapeutic family and group home care
  • Substance dependency inpatient and day treatment services
  • School-based services

All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers manual.

Coverage of Specific Services

Medicaid covers the same services for members who are enrolled in Medicaid and IHS as those members who are enrolled in Medicaid only. All requirements for Medicaid services (such as prior authorization, Passport and others) also apply to Medicaid enrolled members who qualify for IHS services.

Importance of Fee Schedules

The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (IHS/tribal 638 are provider type 57). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website.

 

End of Covered Services Chapter

 

Passport to Health Program

 

What Is Passport to Health? (ARM 37.86.5101–5120)

Passport to Health is the managed care program for Montana Medicaid and Healthy Montana Kids (HMK) Plus members. The four Passport programs encourage and support Medicaid and HMK Plus members and providers in establishing a medical home and in ensuring the appropriate use of Medicaid and HMK Plus services:

  • Passport
  • Team Care
  • Nurse First Advice Line
  • Health Improvement Program

For more information regarding Passport to Health, see the Passport to Health manual available on the Provider Information website.

Passport and Indian Health Service

Members who are eligible for both Indian Health Service (IHS)/tribal 638 and Medicaid may choose an IHS/tribal 638 provider or another provider as their Passport provider. Members who are eligible for IHS do not need a referral from their Passport provider to obtain services from IHS. However, if IHS refers the member to a non-IHS provider, the Passport provider must provide the referral.

Passport information is found in the Passport to Health manual, available on the Provider Information website.

 

End of Passport to Health Program Chapter

 

Coordination of Benefits

 

For coordination of benefits information, refer to the Third Party Liability section in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual, available on the Provider Information website.

 

End of Coordination of Benefits Chapter

 

Billing Procedures

 

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

See the General Information for Providers manual for additional information on member cost sharing.

IHS Revenue Codes

IHS providers may bill Medicaid with the revenue codes shown in the current fee schedule.

Billing for Specific Services

Prior authorization is required for some services. Passport and prior authorization are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers manual.)

Some services provided by an IHS are billed with the IHS provider number and codes specific to IHS. Other services require the IHS to enroll as a Medicaid provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the Medicaid provider number assigned to that provider type. All providers must be enrolled with Medicaid before billing for services.

Every claim for Medicaid services must indicate the provider of service. Claims for services rendered in IHS facilities are submitted using the IHS facility’s provider number. However, when services are rendered in a non-IHS facility, the claim should be submitted using the individual’s provider number.

IHS physicians do not receive reimbursement directly from Medicaid but from the IHS. IHS providers must show the Billings Area Indian Health Service as the “pay to” address on the enrollment form.

 

End of Billing Procedures Chapter

 

Remittance Advices and Adjustments

 

For information on remittance advices and adjustments, see the General Information for Providers manual, available on the website.

 

End of Remittance Advices and Adjustments Chapter

 

How Payment Is Calculated

 

Overview

Though providers do not need the information in this chapter to submit claims to Montana Medicaid, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Montana Medicaid operates the IHS/tribal 638 facilities according to the Medicaid State Plan, which states that services provided by IHS/tribal 638 facilities are paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services for IHS as set forth in the Federal Register. Subsequent payment adjustments will be made pursuant to changes published in the Federal Register.

Section 1905(b) of the Social Security Act (the Act) provides that 100% Federal Medical Assistance Percentages (FMAP) is available to states for amounts spent on medical assistance received through an IHS facility whether operated by the IHS or by an Indian tribe or tribal organization, as defined in Sec. 4 of the Indian Health Care Improvement Act.

Physician services provided by IHS physicians in non-IHS facilities are not eligible for 100% federal funds, but rather at the regular federal/state match rate of approximately 65% federal funds and 35% state funds. Montana Medicaid pays for these physician services by utilizing the Medicare Resource-Based Relative Value Scale (RBRVS) with a Montana-specific conversion factor.

IHS Rates Established by CFR

IHS/tribal 638 facilities are paid in accordance with the most current Federal Register Notice, published by IHS and approved by CMS.

Services provided by facilities of the IHS, which include at the option of a tribe or tribal organization, services by tribal 638 facilities funded by Title I or Title V of the Indian Self-Determination and Education Assistance Act (P.L. 93-638), are paid at the rates negotiated between CMS and the IHS and published in the Federal Register.

Payment for IHS/tribal 638 inpatient hospital services is made in accordance with the inpatient hospital per diem rate published in the Federal Register by the IHS. Payment for IHS/tribal 638 outpatient services is made in accordance with the outpatient per-visit rate published by the IHS in the Federal Register.

 

End of How Payment is Calculated Chapter

 

Appendix A: Forms

 

The forms listed as examples below and others are found on the Forms page of the Provider Information website.

  • Individual Adjustment Request
  • Paperwork Attachment Cover Sheet

 

End of Appendix A: Forms Chapter

 

Definitions and Acronyms

 

See the Definitions and Acronyms page of the Provider Information website for additional definitions and acronyms.

Date of Submission

The date the claim is stamped received by Montana Medicaid. A claim lost in the mail is not considered received.

Indian Health Service (IHS)

IHS provides health services to American Indians and Alaska Natives.

Indian Health Service (IHS) Facility

An IHS facility is an entity that is either owned or leased by the IHS of the Public Health Service. The IHS equates facilities that are leased by IHS to those that are owned by IHS for purposes of defining an IHS facility. IHS keeps a specific listing of its owned and leased facilities. Some IHS facilities, although owned by IHS, may be operated by a tribe or tribal organization.

Patient Day

An individual present and receiving medical services in a facility for a whole 24-hour period. Although an individual may not be present for a whole 24-hour period on the day of admission, such a day will be considered a patient day. The day of discharge will not be counted as a patient day except when the patient is admitted and discharged on the same day.

Tribal 638 Facility

A facility or location owned and operated by a federally recognized American Indian Tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

 

End of Definitions and Acronyms Chapter

 

Index

Previous editions of this manual contained an index.

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.
  2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.
  3. Site SearchSearch the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

End of Index Chapter

End of Indian Health Services/Tribal 638 Manual