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.
This edition has three search options.
Updated 04/12/2022
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.
This publication supersedes any and all previous DPHHS Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.
Updated October 2017 and April 2022.
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.
04/12/2022
10/20/2017
First edition of the Montana Medicaid Tribal Health Improvement Program Manual.
Manual Organization
Manual Maintenance
Rule References
Overview
Tier 1 Activities
Tier 2 Activities
Tier 3 Activities
Tier 1
Tier 2
Tier 3
(406) 444-4540
(406) 444-1861 Fax
DPHHS IHS/Tribal 638 Program Officer
Hospital and Physician Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
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.
This manual provides information specifically for Tribal Health Improvement Program (T-HIP) services. 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 responsible both manuals.
A table of contents and an index allow you to quickly find answers to most questions. 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.
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.
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. In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are applicable to T-HIP:
The Tribal Health Improvement Program (T-HIP) is a historic partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Medicaid and residing on a reservation. This manual will give you an overview of the Tribal Health Improvement Program, goals of the program and a link to the forms necessary to complete the documentation required for program participation.
T-HIP services are designed to help members:
Federally recognized tribes in Montana are the only eligible entities able to participate in and administer T-HIP. T-HIP is a three tier program. A tribe may choose which level they wish to participate. Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by the Department. Services provided under Tier 1 seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport primary care provider. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities. Activities generally focus on improving the health of a population rather than individual members. (i.e. obesity prevention program for grade school youth.)
Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation. To enroll as a T-HIP provider the following criteria must be met:
For Tier 1, Tribes must employ or contract for:
For Tier 2 and Tier 3 services, Tribes must employ or contract with adequate personnel to provide the services as defined. Staff may include people with culturally relevant and/or practical experience, health care or social service backgrounds. These staff must be supervised by the Medical Director that is employed or contracted by the Tribe.
Eligible Members are those who meet the following criteria:
• Enrolled in Medicaid and Passport to Health Program;:
• Is an American Indian/Alaska Native;
• Is Indian Health Service (IHS) eligible;
• Lives within the exterior reservation boundaries; and
• Has not opted out of T-HIP.
Assistance with and referrals to local resources such as social services, housing and other life problems that could prevent members from seeking care for medical conditions.
The Tribe must comply with the following reporting requirements:
Status | Requirement |
---|---|
Active |
|
Pending |
|
Cannot Contact |
|
Do Not Contact |
|
T-HIP programs must keep appropriate records in the event of an audit. Record keeping standards can be found in ARM 37.85.414. Records should reflect care coordination services provided as outlined in this manual to individual members in Tier 1. Tier 2 and Tier 3 records should reflect the approved Tier Request Forms and agreed upon reporting measurements. Records may also include sign-in sheets, program curriculum, advertisements, event write ups, expenditure reports, etc.
The T-HIP provider may request disenrollment of a member by submitting in writing to the Department reasons for the requested disenrollment. The provider may not request disenrollment because of:
Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and HMK Plus members. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:
Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, midlevel practitioner, or primary care clinic.
For more information regarding Passport to Health, see the Passport to Health
manual available on the Provider Information website.
T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP services provided. Providers will receive a per member per month fee that is automatically generated by the Department and paid to the T-HIP enrolled providers monthly.
T-HIP providers receive a per member per month (PMPM) fee for each eligible Passport to Health member who lives within the exterior reservation boundaries. The PMPM fee is based on a three tiered system and payments at each level are inclusive. Payment will not be prorated for a partial month on service provision.
The T-HIP PMPM fee is not paid for members who have voluntarily disenrolled (opted out) of T-HIP.
T-HIP funded services may not duplicate services furnished or reimbursed under another Montana Medicaid State Plan, Department or Federally funded program (for example, Medicaid State Plan targeted case management services). A tribal provider may provide and be reimbursed for both T-HIP and other Medicaid covered services that they meet the qualifications for. (Example: Tribe provides both dialysis and T-HIP services.) However, a single encounter by T-HIP staff may not be used to fulfill the requirements for both provider types. (Example: Certified diabetes educator office visit is not both a separately billable service and a T-HIP service.)
Care Coordinator means a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker, Health Educator or Paraprofessional who specializes in and provides care coordination services in Tier 1. Care Coordinators work under the direct supervision of a medical director, physician, or advance practice registered nurse who is employed by or under contract with the Tribe.
Enhanced Care Coordination (ECC) is the array of services provided by the Tier 1 Care Coordinator. Services include guiding members through healthcare options, coordinating and implementing care plans, advocating on the member’s behalf, and providing community resource information. One of the purposes of enhanced care coordination is to improve the communication and coordination link between the member and the Passport primary care provider. Enhanced care coordination also includes utilizing quality measures to improve health outcomes.
Medical Director is defined as a Physician (an M.D. or a D.O.) or an Advance Practice Registered Nurse.
Member or Eligible Member means a person who is enrolled in the Medicaid Passport to Health Program and who also meets the following requirements:
Paraprofessional means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional. This individual must have a minimum of an associate’s degree in behavioral sciences or a related field with two years of closely related work experience. Qualifying experience may be substituted, year for year, for education.
Per Member Per Month (PMPM) means the comprehensive monthly payment methodology that Medicaid utilizes to pay for all T-HIP services for an eligible member. The PMPM reimbursement is only for T-HIP services. Other Medicaid covered services can be billed and paid separately. The PMPM rate is a set amount of money: Tier 1, 2, and 3 each have different PMPM rates. A tribal provider does not bill the Department for T-HIP services on an individual basis when a service is provided; the Department will identify eligible members and initiate payment. PMPM payments are made on behalf of all eligible members, regardless of whether a particular eligible member received T-HIP services that month.
T-HIP Provider means a health program operated by a federally recognized tribe who has an approved 638 agreement with Indian Health Service (through compact or contract) and a signed Task Order with the State.
Tier 1 is the core building block for the Tribal Health Improvement Program. In order to participate, a Tribe must implement Tier 1 and serve eligible members identified by the Department as high cost or high risk. Tier 1 services must be supervised by a Medical Director.
Tier 2 requires the implementation of Tier 1 in addition to the implementation of two (2) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members). Tier 2 services must be supervised by a Medical Director.
Tier 3 requires the implementation of Tier 1 in addition to the implementation of four (4) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members). Tier 3 services must be supervised by a Medical Director.
Service Area means the area within the exterior boundaries of the reservation.
The forms listed below and others are available on the Forms page of the Montana Healthcare Programs Provider Information website. See the site index in the left menu on https://medicaidprovider.mt.gov/ .
• T-HIP Tier Request Form
• T-HIP Provider Referral Form
• T-HIP opt-out form
This manual contains search functions in lieu of an index.
This edition has three search options.
This publication supersedes any and all previous DPHHS Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.
Updated October 2017 and April 2022.
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.
04/11/2022
Removed Nurse First Advice Line references.
10/20/2017
First edition of the Montana Medicaid Tribal Health Improvement Program Manual.
Manual Organization
Manual Maintenance
Rule References
Overview
Tier 1 Activities
Tier 2 Activities
Tier 3 Activities
Tier 1
Tier 2
Tier 3
(406) 444-4540
(406) 444-1861 Fax
DPHHS IHS/Tribal 638 Program Officer
Hospital and Physician Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
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.
This manual provides information specifically for Tribal Health Improvement Program (T-HIP) services. 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 responsible both manuals.
A table of contents and an index allow you to quickly find answers to most questions. 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.
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.
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. In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are applicable to T-HIP:
The Tribal Health Improvement Program (T-HIP) is a historic partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Medicaid and residing on a reservation. This manual will give you an overview of the Tribal Health Improvement Program, goals of the program and a link to the forms necessary to complete the documentation required for program participation.
T-HIP services are designed to help members:
Federally recognized tribes in Montana are the only eligible entities able to participate in and administer T-HIP. T-HIP is a three tier program. A tribe may choose which level they wish to participate. Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by the Department. Services provided under Tier 1 seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport primary care provider. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities. Activities generally focus on improving the health of a population rather than individual members. (i.e. obesity prevention program for grade school youth.)
Federally recognized tribes may choose to operate this program for their Native American members within the exterior boundaries of their reservation. To enroll as a T-HIP provider the following criteria must be met:
For Tier 1, Tribes must employ or contract for:
For Tier 2 and Tier 3 services, Tribes must employ or contract with adequate personnel to provide the services as defined. Staff may include people with culturally relevant and/or practical experience, health care or social service backgrounds. These staff must be supervised by the Medical Director that is employed or contracted by the Tribe.
Eligible Members are those who meet the following criteria:
• Enrolled in Medicaid and Passport to Health Program;:
• Is an American Indian/Alaska Native;
• Is Indian Health Service (IHS) eligible;
• Lives within the exterior reservation boundaries; and
• Has not opted out of T-HIP.
Assistance with and referrals to local resources such as social services, housing and other life problems that could prevent members from seeking care for medical conditions.
The Tribe must comply with the following reporting requirements:
Status | Requirement |
---|---|
Active |
|
Pending |
|
Cannot Contact |
|
Do Not Contact |
|
T-HIP programs must keep appropriate records in the event of an audit. Record keeping standards can be found in ARM 37.85.414. Records should reflect care coordination services provided as outlined in this manual to individual members in Tier 1. Tier 2 and Tier 3 records should reflect the approved Tier Request Forms and agreed upon reporting measurements. Records may also include sign-in sheets, program curriculum, advertisements, event write ups, expenditure reports, etc.
The T-HIP provider may request disenrollment of a member by submitting in writing to the Department reasons for the requested disenrollment. The provider may not request disenrollment because of:
Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and HMK Plus members. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:
Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, midlevel practitioner, or primary care clinic.
For more information regarding Passport to Health, see the Passport to Health
manual available on the Provider Information website.
T-HIP is different from other services Montana Medicaid pays for in that providers are not required to bill for T-HIP services provided. Providers will receive a per member per month fee that is automatically generated by the Department and paid to the T-HIP enrolled providers monthly.
T-HIP providers receive a per member per month (PMPM) fee for each eligible Passport to Health member who lives within the exterior reservation boundaries. The PMPM fee is based on a three tiered system and payments at each level are inclusive. Payment will not be prorated for a partial month on service provision.
The T-HIP PMPM fee is not paid for members who have voluntarily disenrolled (opted out) of T-HIP.
T-HIP funded services may not duplicate services furnished or reimbursed under another Montana Medicaid State Plan, Department or Federally funded program (for example, Medicaid State Plan targeted case management services). A tribal provider may provide and be reimbursed for both T-HIP and other Medicaid covered services that they meet the qualifications for. (Example: Tribe provides both dialysis and T-HIP services.) However, a single encounter by T-HIP staff may not be used to fulfill the requirements for both provider types. (Example: Certified diabetes educator office visit is not both a separately billable service and a T-HIP service.)
Care Coordinator means a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker, Health Educator or Paraprofessional who specializes in and provides care coordination services in Tier 1. Care Coordinators work under the direct supervision of a medical director, physician, or advance practice registered nurse who is employed by or under contract with the Tribe.
Enhanced Care Coordination (ECC) is the array of services provided by the Tier 1 Care Coordinator. Services include guiding members through healthcare options, coordinating and implementing care plans, advocating on the member’s behalf, and providing community resource information. One of the purposes of enhanced care coordination is to improve the communication and coordination link between the member and the Passport primary care provider. Enhanced care coordination also includes utilizing quality measures to improve health outcomes.
Medical Director is defined as a Physician (an M.D. or a D.O.) or an Advance Practice Registered Nurse.
Member or Eligible Member means a person who is enrolled in the Medicaid Passport to Health Program and who also meets the following requirements:
Paraprofessional means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional. This individual must have a minimum of an associate’s degree in behavioral sciences or a related field with two years of closely related work experience. Qualifying experience may be substituted, year for year, for education.
Per Member Per Month (PMPM) means the comprehensive monthly payment methodology that Medicaid utilizes to pay for all T-HIP services for an eligible member. The PMPM reimbursement is only for T-HIP services. Other Medicaid covered services can be billed and paid separately. The PMPM rate is a set amount of money: Tier 1, 2, and 3 each have different PMPM rates. A tribal provider does not bill the Department for T-HIP services on an individual basis when a service is provided; the Department will identify eligible members and initiate payment. PMPM payments are made on behalf of all eligible members, regardless of whether a particular eligible member received T-HIP services that month.
T-HIP Provider means a health program operated by a federally recognized tribe who has an approved 638 agreement with Indian Health Service (through compact or contract) and a signed Task Order with the State.
Tier 1 is the core building block for the Tribal Health Improvement Program. In order to participate, a Tribe must implement Tier 1 and serve eligible members identified by the Department as high cost or high risk. Tier 1 services must be supervised by a Medical Director.
Tier 2 requires the implementation of Tier 1 in addition to the implementation of two (2) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members). Tier 2 services must be supervised by a Medical Director.
Tier 3 requires the implementation of Tier 1 in addition to the implementation of four (4) health promotion/ disease prevention programs targeted to a larger population. One of these health promotion/ disease prevention programs could be an expansion of the Tier 1 program (for example, targeting 25% rather than 10% of members). Tier 3 services must be supervised by a Medical Director.
Service Area means the area within the exterior boundaries of the reservation.
The forms listed below and others are available on the Forms page of the Montana Healthcare Programs Provider Information website. See the site index in the left menu on https://medicaidprovider.mt.gov/ .
• T-HIP Tier Request Form
• T-HIP Provider Referral Form
• T-HIP opt-out form
This manual contains search functions in lieu of an index.
This edition has three search options.