Indian Health Service
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 manual has 3 search options.
- 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 are discussed in the manual.
- 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 are discussed in just that chapter.
- Site Search. Search 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.
Updated 07/26/2023
Complete Indian Health Service Provider 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 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 are 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 are discussed in just that chapter.
3. Site Search. Search 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.
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, August 2017, January 2020, and July 2023.
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
07/26/2023
- Full review and changes to entire manual.
- Tribal 638 now has a separate manual and provider type page.
07/28/2022
- Updated Passport to Health Chapter to remove Nurse First Advice references.
- Updated Index to Search Options.
01/01/2020
- Cost Share references removed from the Billing Procedures Chapter.
- Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
- Terms "client" and "patient" replaced with "member".
08/15/2017
Indian Health Service/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
Covered Services
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment Is Calculated
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS IHS Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Indian Health Service Area Office
(406) 247-7100 Main
Billings Area IHS Office
2900 4th Avenue North
Billings, MT 59101
Indian Health Service Units
| Unit | Address | Main Number | Fax |
| Blackfeet Service Unit | Blackfeet Community Hospital P.O. Box 760 Browning, MT 59417 |
(406) 338-6100 | (406) 338-2959 |
| Blackfeet Service Unit | Heart Butte Health Station P.O. Box 80 Heart Butte, MT 59448 |
(406) 338-2151 | (406) 338-5613 |
| Crow Service Unit | Crow/Northern Cheyenne Hospital P.O. Box 9 Crow Agency, MT 59022 |
(406) 638-3500 | (406) 638-3569 |
| Crow Service Unit | Lodge Grass Health Clinic P.O. Box AD Lodge Grass, MT 59050 |
(406) 639-2317 | (406) 639-2976 |
| Crow Service Unit | Pryor Health Station P.O. Box 9 Pryor, MT 59066 |
(406) 259-8238 | (406) 259-8290 |
| Fort Belknap Service Unit | Fort Belknap Hospital 669 Agency Main Street Harlem, MT 59526 |
(406) 353-3100 | (406) 353-3227 |
| Fort Belknap Service Unit | Eagle Child Health Station P.O. Box 610 Hays, MT 59527 |
(406) 673-3777 | (406) 673-3835 |
| Fort Peck Service Unit | Chief Redstone Clinic 550 6th Avenue North P.O. Box 729 Wolf Point, MT 59201 |
(406) 653-1641 | N/A |
| Fort Peck Service Unit | Verne E. Gibbs Clinic 107 H. Street P.O. Box 67 Poplar, MT 59255 |
(406) 768-3491 | N/A |
| Little Shell Chippewa Service Unit | Little Shell Health Clinic 425 Smelter Ave NE Great Falls, MT 59404 |
(406) 546-0665 | N/A |
| Northern Cheyenne Service Unit | Lame Deer Health Center P.O. Box 70 Lame Deer, MT 59043 |
(406) 477-4400 | (406) 477-4427 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Indian Health Service (IHS) providers who provide services to members who are eligible for both Montana Healthcare Programs 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 outlines the chapters in this manual. 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
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home 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 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 Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs 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. Choose the Contact Us option under the ARM menu item across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs 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 providers’ claims as quickly as possible. 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. Montana Healthcare Programs 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) providers who provide services to members who are eligible for both Montana Healthcare Programs and IHS. Services provided to members 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 (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
IHS providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physicians' current license from another state would satisfy this requirement.
Additional information for Physician requirements is available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at an IHS are not eligible to enroll with Montana Healthcare Programs.
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 aged 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
- 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
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and IHS as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for IHS services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers Manual.
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 (the majority of the services provided are listed under the IHS fee schedule). 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 on the Provider Information website 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 also 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 members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Indian Health Service
Members who are eligible for both IHS and Montana Medicaid may choose an IHS 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. If IHS refers the member to a non-IHS provider or specialist, a Passport or Team Care referral is not needed.
Refer to the Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all Medicaid members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking a PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed. PA criteria for most services are available on the Provider Information website.
- PA criteria for most services are available on the Provider Information website.
- If a service required requires PA, the requirements exist for all Montana Healthcare Program members. PA is usually obtained through the Department or a PA contractor.
- For PA criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information Website.
Services will not be reimbursed when PA 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 (COB)
For COB 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 Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 copayment will not be assessed.
IHS Revenue Codes
IHS providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) 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 provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider type. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for 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.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current IHS fee schedule. | IHS Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current IHS fee schedule. | IHS Provider |
| Dental | Refer to the current IHS fee schedule. | IHS Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current IHS fee schedule. | IHS Provider |
| EPSDT (children aged 20 and under) | Refer to the current IHS fee schedule. | IHS Provider |
| Eyeglasses Dispensing | Refer to the current IHS fee schedule. | IHS Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. | HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current IHS fee schedule. | IHS Provider |
| Laboratory | Refer to the current IHS fee schedule. | IHS Provider |
| Licensed Professional Counselor | Refer to the current IHS fee schedule. | IHS Provider |
| Medical/Surgical Supplies | Refer to the current IHS fee schedule. | IHS Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Optical Exam | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Clinic | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Surgery | Refer to the current IHS fee schedule. | IHS Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current IHS fee schedule | IHS Provider |
| Podiatry | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology, Diagnostic | Refer to the current IHS fee schedule. | IHS Provider |
| Speech Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Telemedicine | Refer to the current IHS fee schedule. | IHS Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual. | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
IHS Rates Established by the Code of Federal Regulations (CFR)
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Payments to IHS enrolled facilities are made in accordance with the Medicaid State Plan, which states that services provided by IHS 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. IHS facilities are paid in accordance with the current Federal Register Notice. Subsequent payment adjustments will be made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Search Options
This manual has 3 search options.
- 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 are discussed in the manual.
- 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 are discussed in just that chapter.
- Site search. Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.
End of Search Options Chapter
End of Indian Health Services Manual
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, August 2017, January 2020, and July 2023.
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
07/26/2023
- Full review and changes to entire manual.
- Tribal 638 now has a separate manual and provider type page.
07/28/2022
- Updated Passport to Health Chapter to remove Nurse First Advice references.
- Updated Index to Search Options.
01/01/2020
- Cost Share references removed from the Billing Procedures Chapter.
- Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
- Terms "client" and "patient" replaced with "member".
08/15/2017
Indian Health Service/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
Covered Services
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment Is Calculated
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS IHS Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Indian Health Service Area Office
(406) 247-7100 Main
Billings Area IHS Office
2900 4th Avenue North
Billings, MT 59101
Indian Health Service Units
| Unit | Address | Main Number | Fax |
| Blackfeet Service Unit | Blackfeet Community Hospital P.O. Box 760 Browning, MT 59417 |
(406) 338-6100 | (406) 338-2959 |
| Blackfeet Service Unit | Heart Butte Health Station P.O. Box 80 Heart Butte, MT 59448 |
(406) 338-2151 | (406) 338-5613 |
| Crow Service Unit | Crow/Northern Cheyenne Hospital P.O. Box 9 Crow Agency, MT 59022 |
(406) 638-3500 | (406) 638-3569 |
| Crow Service Unit | Lodge Grass Health Clinic P.O. Box AD Lodge Grass, MT 59050 |
(406) 639-2317 | (406) 639-2976 |
| Crow Service Unit | Pryor Health Station P.O. Box 9 Pryor, MT 59066 |
(406) 259-8238 | (406) 259-8290 |
| Fort Belknap Service Unit | Fort Belknap Hospital 669 Agency Main Street Harlem, MT 59526 |
(406) 353-3100 | (406) 353-3227 |
| Fort Belknap Service Unit | Eagle Child Health Station P.O. Box 610 Hays, MT 59527 |
(406) 673-3777 | (406) 673-3835 |
| Fort Peck Service Unit | Chief Redstone Clinic 550 6th Avenue North P.O. Box 729 Wolf Point, MT 59201 |
(406) 653-1641 | N/A |
| Fort Peck Service Unit | Verne E. Gibbs Clinic 107 H. Street P.O. Box 67 Poplar, MT 59255 |
(406) 768-3491 | N/A |
| Little Shell Chippewa Service Unit | Little Shell Health Clinic 425 Smelter Ave NE Great Falls, MT 59404 |
(406) 546-0665 | N/A |
| Northern Cheyenne Service Unit | Lame Deer Health Center P.O. Box 70 Lame Deer, MT 59043 |
(406) 477-4400 | (406) 477-4427 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Indian Health Service (IHS) providers who provide services to members who are eligible for both Montana Healthcare Programs 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 outlines the chapters in this manual. 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
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home 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 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 Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs 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. Choose the Contact Us option under the ARM menu item across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs 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 providers’ claims as quickly as possible. 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. Montana Healthcare Programs 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) providers who provide services to members who are eligible for both Montana Healthcare Programs and IHS. Services provided to members 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 (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
IHS providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physicians' current license from another state would satisfy this requirement.
Additional information for Physician requirements is available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at an IHS are not eligible to enroll with Montana Healthcare Programs.
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 aged 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
- 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
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and IHS as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for IHS services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers Manual.
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 (the majority of the services provided are listed under the IHS fee schedule). 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 on the Provider Information website 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 also 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 members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Indian Health Service
Members who are eligible for both IHS and Montana Medicaid may choose an IHS 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. If IHS refers the member to a non-IHS provider or specialist, a Passport or Team Care referral is not needed.
Refer to the Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all Medicaid members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking a PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed. PA criteria for most services are available on the Provider Information website.
- PA criteria for most services are available on the Provider Information website.
- If a service required requires PA, the requirements exist for all Montana Healthcare Program members. PA is usually obtained through the Department or a PA contractor.
- For PA criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information Website.
Services will not be reimbursed when PA 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 (COB)
For COB 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 Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 copayment will not be assessed.
IHS Revenue Codes
IHS providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) 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 provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider type. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for 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.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current IHS fee schedule. | IHS Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current IHS fee schedule. | IHS Provider |
| Dental | Refer to the current IHS fee schedule. | IHS Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current IHS fee schedule. | IHS Provider |
| EPSDT (children aged 20 and under) | Refer to the current IHS fee schedule. | IHS Provider |
| Eyeglasses Dispensing | Refer to the current IHS fee schedule. | IHS Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. | HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current IHS fee schedule. | IHS Provider |
| Laboratory | Refer to the current IHS fee schedule. | IHS Provider |
| Licensed Professional Counselor | Refer to the current IHS fee schedule. | IHS Provider |
| Medical/Surgical Supplies | Refer to the current IHS fee schedule. | IHS Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Optical Exam | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Clinic | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Surgery | Refer to the current IHS fee schedule. | IHS Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current IHS fee schedule | IHS Provider |
| Podiatry | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology, Diagnostic | Refer to the current IHS fee schedule. | IHS Provider |
| Speech Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Telemedicine | Refer to the current IHS fee schedule. | IHS Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual. | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
IHS Rates Established by the Code of Federal Regulations (CFR)
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Payments to IHS enrolled facilities are made in accordance with the Medicaid State Plan, which states that services provided by IHS 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. IHS facilities are paid in accordance with the current Federal Register Notice. Subsequent payment adjustments will be made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Search Options
This manual has 3 search options.
- 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 are discussed in the manual.
- 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 are discussed in just that chapter.
- Site search. Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.