This section addresses policy, payment and billing for health care services provided by the federal government through Indian Health Service (IHS) facilities, or by tribes through facilities funded by Title I or III of the Indian Self-Determination and Education Assistance Act (Public Law 93-638), as amended.
Throughout this section, facilities of the federal Indian Health Service will be referred to as “IHS facilities”; facilities operated by federally recognized Indian tribes with Public Law 93-638 funding will be referred to as “tribal facilities.” Facilities operated by tribes that are not federally-recognized should refer to the MHCP Provider Manual for policy, payment, and billing information.
This section provides special instructions for billing the Minnesota Health Care Program (MHCP) covered health care services provided to MHCP recipients through an IHS or tribal facility. In addition to the IHS- and tribal-specific policies and coverage, these facilities must also comply with all of the standard MHCP policies and coverage guidelines found in the MHCP Provider Manual. Refer to other sections of the MHCP Provider Manual for information about standard coverage and billing policy.
An eligible provider is an individual or group enrolled in MHCP, who meets MHCP licensure criteria or, in some instances, tribal licensure or certification as established with the Commissioner. To enroll a provider, contact MHCP Provider Enrollment at (651) 431-2700 or 1-800-366-5411, option 5.
Tribal and IHS providers must meet the same service and licensure requirements as all other MHCP-enrolled providers, with the following exceptions:
The following list identifies health professional types that may be eligible to bill MHCP (this list is not all-inclusive):
Provider Type Home Page Links
American Indians (AI) and Alaska Natives (AN) eligible for one of the Minnesota Health Care Programs (MHCP), including Medical Assistance (MA), General Assistance Medical Care (GAMC), and MinnesotaCare, are eligible for all covered services of the applicable MHCP program, even if they are also eligible for services provided through the IHS or tribal facilities.
All services billed to MHCP must be:
Under MS 256B.0625, subd.34, all covered MHCP services provided through IHS and tribal facilities are eligible for payment. A tribal provider may offer services beyond the scope of IHS facility services, including home health, chemical dependency, mental health, and transportation. Tribal governments may also seek certification from DHS to provide Child Welfare Targeted Case Management (CW-TCM) services and Relocation Service Coordination (RSC).
Services that are not covered services are listed in the related chapters of the MHCP Provider Manual.
Services for GAMC recipients and for MinnesotaCare recipients who are adults without children are paid according to the payment methodology noted in the applicable individual service sections.
All services provided to MA recipients at an IHS or tribal facility must be billed under the IHS or tribal facility provider number. IHS and tribal providers must include the treating provider’s MHCP provider number or National Provider Number (NPI) on all claim lines requiring a treating provider number. Claims submitted without a treating provider number when one is required will be denied. Please note:
All covered services must be billed in the appropriate claim formats (e.g., 837P (professional) claim format, ADA, Pharmacy NCPDP). All services provided must be included with the claim, even if only one encounter payment will be generated.
Services billed under an individual provider’s number will not be paid at the IHS encounter rate
Child and Teen Checkups (C&TC) Services
Submit claims for Child and Teen Checkups services using C&TC policy and billing instructions. All services provided must be included with the claim, even if only one encounter payment will be generated.
Outpatient Hospital Ambulatory Surgical Services
Whenever an ambulatory surgical service (the recipient does not require overnight hospital care) is provided:
Medical supplies and prescription drugs provided and diagnostic services performed on the date of service are considered part of the encounter with the health professional and no separate payments are made.
Third Party Liability (TPL)
TPL coverage, including veterans benefits, private accident insurance, HMO coverage and other health care coverage held by or on behalf of an MHCP recipient is primary to MHCP except when the TPL is tribal insurance. Submit claims with tribal insurance by:
Inpatient Hospital Services
All inpatient hospital services are covered under the payment of the inpatient per diem rate established by the IHS. Requirements such as admission certification, second medical opinion (SMO), and authorization apply. Refer to the following sections; Hospital Services, Inpatient Hospital Authorization, Physician and Professional Services, and Authorization.
Inpatient Physician Services
MA pays for inpatient physician services that meet the requirements under the approved State Medicaid plan at the MA fee-for-service rates.
Outpatient Services of IHS Facilities
All MA covered services including any medical supplies or prescription drugs provided through an IHS outpatient facility are paid at the IHS encounter rate. Pharmacies, including mail order pharmacies, which are providing drugs for an IHS outpatient visit should bill the IHS facility and not MHCP for the drugs dispensed.
Outpatient Services of Tribal Facilities
MA covered services provided through tribal facilities may be paid at either the IHS encounter rate or the applicable fee-for-service rate. Tribes may choose either payment rate for each separate 638 facility. All services of a single facility will be paid at the chosen rate. Service categories eligible for reimbursement at the IHS outpatient reimbursement rate are:
An encounter for a tribal or IHS facility means a face-to-face visit between a recipient eligible for MA and any health professional at or through an IHS or tribal service location for the provision of MA covered services within a 24-hour period ending at midnight.
Encounters with more than one health professional and multiple encounters with the same professional, within the same service category, that take place in the same 24-hour period, constitute a single encounter. An exception to this is when the recipient, after the first visit, suffers an illness or injury requiring additional diagnosis or treatment. When such a second medically necessary encounter occurs, the second claim must include both the 22 and 76 modifiers, and an attachment explaining the circumstances supporting the second encounter request for payment.
GAMC and MinnesotaCare Payment to IHS Facilities and Tribal Facilities
Services provided to GAMC recipients and to MinnesotaCare recipients who are adults without children must be billed according to the requirements designated for each service. The IHS per day and per visit rates do not apply to these recipients.
MA – PMAP or Fee-For-Service
IHS encounter rate
IHS encounter rate or fee-for-service rate, as elected by tribe
Families with children, pregnant Women
IHS encounter rate
IHS encounter rate or fee-for-service rate, as elected by tribe
Adults without children
IHS and Tribal
Established rates for specific provider types – check payment methodology and rates in the appropriate section of the MHCP Provider Manual
Home Health Agency and Visiting Nurse Services
Home health agency services and visiting nurse services qualify as IHS or tribal encounters when the services are:
CW-TCM and RSC Services
CW-TCM services and RSC services are not paid at the IHS encounter rate. CW-TCM services are paid at the established IHS/tribal CW-TCM rate. RSC is covered at the DHS established RSC rate.
Payments to IHS and tribal providers for ambulance and special transportation services are made independent of IHS and tribal inpatient or outpatient encounter claims.
The IHS outpatient encounter rate is paid when:
The IHS inpatient per diem rate is paid when:
When a second transportation service is medically necessary on the same service date, payment for the second trip is made when the services are provided by a tribal provider, the destination is one the recipient is eligible to receive services from and the service is covered by MA. Whether the second transportation service payment is at the outpatient or inpatient rate depends upon whether the recipient was admitted within 24 hours of the ambulance trip.
Payment limits for a given service date are based on the following criteria:
Facility Support Staff: Individuals employed by the health care facility to support the services provided by the facility’s health professionals. These individuals do not generate billable encounters. Examples of facility support staff are: clinic managers; RNs and LPNs not functioning/acting as physician extenders or visiting nurses; lab technicians; and x-ray technicians.
Indian Health Service (IHS) Facility: A hospital, medical or dental clinic, or pharmacy established and operated by the Federal Indian Health Service.
IHS Inpatient Per Diem Rate: The IHS inpatient per diem rate is the payment amount established to cover services provided to an inpatient at a hospital that is part of the Federal Indian Health Service.
Outpatient Encounter: An encounter means a face-to-face visit between a recipient and any health professional at an IHS or tribal facility. Multiple encounters with the same professional or with more than one health professional, within the same service category, on the same day, at a single IHS or tribal location, constitute a single encounter. An exception to this is when the recipient, after the first visit, suffers an illness or injury requiring additional diagnosis or treatment.
Tribal 638 Facility: Tribally owned facilities funded by Title I or III of the Indian Self-Determination and Education Assistance Act, including all facilities under contract, compact, or receiving grants from the IHS. The tribal facility is operated by a federally-recognized tribe under a funding agreement with IHS. Tribal facilities may elect to be paid at the IHS rates or at fee-for-service rates.