This manual is designed to be used in conjunction with other sections of the Utah Medicaid Provider Manual, such as Section I: General Information of the Utah Medicaid Provider Manual (Section I: General Information) and the Physician Services Utah Medicaid Provider Manual at https://medicaid.utah.gov.
The information in this manual represents available services when medically necessary. Services may be expanded if the proposed services are medically appropriate and are more cost effective than alternative services.
The United States Government has an historical and unique legal relationship with and resulting responsibility to American Indian and Alaska Native (AI/AN) individuals. The health care delivery system for AI/AN tribes with this unique government-to-government relationship consists of Indian Health Services (IHS)-owned and operated health care facilities, IHS-owned facilities that are operated by AI/AN tribes or tribal organizations under 638 agreements (contracts, grants, or compacts), and facilities owned and operated by tribes or tribal organizations under such agreements. Medicaid services are available to AI/AN individual who apply and are found eligible under section 1905(b) of the Social Security Act, 42 U.S.C. 1396d. Centers for Medicare and Medicaid Services (CMS) allows 100 % Federal Medical Assistance Percentage (FMAP) for Medicaid services furnished to Medicaid eligible AI/ANs.
The Utah Medicaid State Plan applies to reimbursement for services provided at IHS facilities, Tribal 638 Programs, and Urban Indian facilities. Additionally, unless otherwise stated, all other Utah Medicaid rules apply to IHS, Tribal 638 Programs, and Urban Indian clinics.
This manual provides information regarding Medicaid policy and procedures for fee-for-service Medicaid members. This manual is not intended to provide guidance to providers for Medicaid members enrolled in a managed care plan (MCP). A Medicaid member enrolled in an MCP (health, behavioral health or dental plan) must receive services through that plan with some exceptions called “carve-out services,” which may be billed directly to Medicaid.
Refer to the provider manual, Section I: General Information, for information regarding MCPs and how to verify if a Medicaid member is enrolled in an MCP. Medicaid members enrolled in MCPs are entitled to the same Medicaid benefits as fee-for-service members. However, plans may offer more benefits than the Medicaid scope of benefits explained in this section of the provider manual. Contact the Medicaid Member Services hotline at (844) 238-3091 for further information.
Medicaid does not process prior authorization requests for services to be provided to a Medicaid member enrolled in an MCP when the services are the responsibility of the plan. Providers requesting prior authorization for services for a member enrolled in an MCP will be referred to that plan.
Medicaid makes every effort to provide complete and accurate information regarding a member’s enrollment in a managed care plan. However, it is the provider’s responsibility to verify eligibility and plan enrollment for a member before providing services. Therefore, if a Medicaid member is enrolled in a MCP, a fee-for-service claim will not be paid unless the claim is for a “carve-out service.”
Eligibility and plan enrollment information for each member is available to providers from these sources:
Definitions of terms used in other Medicaid programs are available in Section I: General Information. Definitions specific to the content of this manual are provided below.
All Inclusive Rate (AIR): It is based on the rates approved by the Office of Management and Budget (OMB). Each year these rates change based on the negotiated rate between HHS, IHS and OMB. See Federal Register. (AIR is also known as encounter rate)
American Indian/Alaska Native (AI/AN) or "Indian": A member of a tribe, band, or other organized group of Indians, including those tribes, bands or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree or any such member living on, near, or off a reservation.
Behavioral Health services: A professional medical services for the treatment of a mental health and/or addiction disorder(s).
CFR: Code of Federal Regulations
CMS: Centers for Medicare and Medicaid Services
DIH: Division of Integrated Healthcare
DWS: Department of Workforce Services
Encounter: A face-to-face contact between a licensed health care professional and an eligible AI/AN Utah Medicaid member for the provision of medically necessary under Title XIX or Title XXI of the Social Security Act covered services through an IHS, Tribal 638 facility, or urban Indian organization.
Encounter rate: See All Inclusive Rate
Indian Health Services (IHS) or Service: An agency within the Department of Health and Human Services (DHHS), is responsible for providing federal health services to American Indians and Alaska Natives (AI/AN).
I/T/U: The abbreviation for describing the Indian health system, services and programs (Indian Health Service, Tribal 638, and Urban Indian Organization.)
Physician: A doctor of medicine or osteopathy legally authorized to practice medicine and surgery or who is a licensed physician employed by the Federal Government in an IHS facility or who provides services in a Urban Indian Facility or a 638 Tribal Facility.
Tribal Health Program or "638" (PL 94-638): an Indian tribe or tribal organization that operates any health program, service, function, activity or facility funded, in whole or part, by the Service through, or provided for in, a contract or compact with the Service under the Indian Self-Determination and Education Assistance Act (ISDEAA).
Urban Indian Organization (UIO) (PL 94 437, title V): A nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing health activities described in the Indian Health Care Improvement Act (IHCIA).
Procedure codes with accompanying criteria and limitations have been removed from the provider manual and are now found on the Medicaid website Coverage and Reimbursement Lookup Tool at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
Indian Health Services, Tribal 638 Programs, and Urban Indian Organizations (I/T/Us) are considered eligible for participation in the Utah Medicaid Program. To receive reimbursement, an I/T/U must have a current contract on file with the Utah Department of Health and Human Services, Division of Integrated Healthcare (DIH). DIH recognizes that I/T/Us are the payer of last resort, and are not considered creditable health insurance.
Refer to provider manual, Section I: General Information for provider enrollment information.
Indian Health Services, Tribal 638 Programs, and Urban Indian Organizations (I/T/Us) are eligible for participation in the Utah Medicaid Program.
Non-Institutional Provider Application Requirements
Note: IHS providers do not require a Utah license, as long as the provider has a valid license in another state.
Professional Services Requirements (physician, pharmacy, dental, etc.)
Must provide a copy of current professional license, copy from Utah Division of Occupational and Professional Licensing (DOPL) database, or telephone verification from DOPL of professional license from any state. DOPL website: www.dopl.utah.gov.
Hospital Services Requirements
An IHS hospital must be accredited according to Medicaid requirements.
A Medicaid beneficiary is required to present the Medicaid Member Card before each service, and every provider must verify each beneficiary’s eligibility each time and before services are rendered. For more information regarding verifying eligibility, refer to provider manual, Section I: General Information, Verifying Medicaid Eligibility.
For information on how to apply for Medicaid, refer to the provider manual Section I: General Information, Applying for Medicaid, or access the Medicaid website at https://medicaid.utah.gov.
Contacting Medicaid
Medicaid contracts with the Department of Workforce Services (DWS) to process applications from tribal members or representatives for medical services. For tribal member eligibility questions:
For additional covered services, refer to the Coverage and Reimbursement Lookup Tool on the Medicaid website at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
Encounters - Inpatient and Outpatient
Encounters whether inpatient or outpatient, must meet the definition found in chapter 1-3 Definitions and are limited to covered State Plan services. Services include those identified in the State Plan and Title XIX or Title XXI of the Social Security Act.
Refer to the Coverage and Reimbursement Lookup Tool on the Medicaid website at: http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php for additional non-covered services and limitations.
The following are excluded from separate coverage, if part of an encounter, and cannot be reimbursed in addition to the encounter. (This list is not all inclusive.)
I/T/U services not reimbursable under outpatient encounters include:
Service limitations governing the provision of all Utah Medicaid services apply. In addition, the following limitations and requirements apply to services provided by I/T/U facilities.
Multiple Encounters - Outpatients
Medicaid will reimburse for one I/T/U encounter per day, per member; however more than one outpatient visit with a medical professional within a 24-hour period for distinctly different diagnoses may be reported as two encounters. Documentation must include unrelated diagnosis codes.
Members seen at a single office visit with multiple problems are reported as a single encounter. Similar services, even when provided by two different I/T/U health care practitioners, are not considered multiple encounters. Situations that would not be considered multiple encounters provided on the same date of service include, but are not limited to:
Abortion and Sterilization
Federal law governs these services.
(42 CFR 441.203 and Public Law Number 105-78 Section 509 and 510, pertaining to revisions of the Hyde Amendment, 1998).
Refer to Chapter 6-1, Prior Authorization, in this Section for PA requirements.
Pharmacy
I/T/U Pharmacy encounters are limited to one per day, per prescriber. If a prescriber issues multiple prescriptions, the reimbursement will be one AIR. If the pharmacy submits a second prescription by a different prescriber on the same day Medicaid will reimburse a second AIR.
Treatment with medication(s) during a clinic visit is included in the encounter rate. The medication or medication sample are included in the encounter rate.
Prescriptions for medications that are to be filled by a pharmacy are not included in the encounter rate, and must be billed by a qualified enrolled pharmacy through the pharmacy program.
Dental
I/T/U Dental encounters are limited to one per day, per client; however, multiple encounters may be reimbursable if due to an emergency and/or the same member returns on the same day for a second visit with a different diagnosis.
More than one dental visit with a dental professional within a 24-hour period for distinctly different diagnoses may be reported as two encounters. Each service must have distinctly different diagnoses in order to meet the criteria for multiple I/T/U dental encounters.
For example, a member comes to the clinic in the morning for a dental examination, and in the afternoon, the member returns to the office with a broken tooth due to a fall. These are two separate dental encounters and can be billed as two encounters.
Dental claims do not provide diagnosis information therefore the second encounter is denied as a duplicate service. If a second encounter meets the definition above and the claim is denied, contact Medicaid Customer Service. A customer services agent will review the claim, if approved the claim will be reimbursed through manual override of the claim denial.
| Customer Service Hot line | Telephone Number |
|---|---|
| Salt Lake City area, | 801-538-6155 |
| Utah, Idaho, Wyoming, Colorado, New Mexico, Arizona, and Nevada toll-free | 1-800-662-9651 |
| From other states | 1-801-538-6155 |
| From all telephone numbers select option 3, then option 9 | |
Laboratory Procedures
Laboratory procedures performed by an I/T/U outpatient facility (this does not include the independently certified enrolled laboratory) are included in the I/T/U encounter rate.
Behavioral Health Services
I/T/U behavioral health professional outpatient encounters are limited to one per day. Multiple encounters may be reimbursable if due to an emergency and/or if the same member returns on the same day for a second visit with a different diagnosis. Each service must have distinctly different diagnoses in order to meet the criteria for multiple I/T/U encounters. Behavioral Health Services are limited to those services furnished to members at or on behalf of the I/T/U facility.
Refer to the provider manual, Section I: General Information, for detailed billing instructions.
Reimbursement
To receive reimbursement an I/T/U facility must have a current contract on file with the Utah Department of Health, Office of Coverage and Reimbursement.
I/T/Us are the payer of last resort and are not considered credible coverage. I/T/Us must meet one of the following:
Directly employ or contract the services of legally credentialed professional staff that are authorized within their scope of practice under state law to provide the services for which claims are submitted to Utah Medicaid.
OR
I/T/U Physicians may meet all requirements for employment by the Federal Government as a physician and be employed by the Federal Government in an IHS Facility, Urban Program Facility or affiliated with a 638 Tribal Facility.
IHS and Tribal 683 facilities are reimbursed as shown in this table.
| Service/Claim | Reimbursement |
|---|---|
| Inpatient Services | Inpatient All Inclusive Rate per episode per day |
| Outpatient Services | Outpatient All Inclusive Rate per episode per day |
| Inpatient Physician Services | Medicaid fee schedule, plus the rural enhancement (i.e. for physician visits to a member that is inpatient in a hospital) |
| Pharmacy Services | All Inclusive Rate per episode per day |
| Dental Services | All Inclusive Rate per episode per day |
| Crossovers Claims | Utilize the methodology above AIR/Fee for Service and the Medicare payment to calculate the reimbursement |
All Medicaid prior authorization requirements are applicable for these services: orthodontic, physician inpatient, pharmacy, abortion, and sterilization. For prior authorization information, refer to the Medicaid website Coverage and Reimbursement Lookup Tool, http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php or Section I: General Information, Prior Authorization at https://medicaid.utah.gov.
Receipt of prior authorization for abortion or sterilization services requires compliance with specific criteria and special consents obtainable at https://medicaid.utah.gov/utah-medicaid-forms.
A claim must be submitted to Medicaid within 365 days from the date of service. The date of service, or “from” date on the claim, begins the count for the 365 days to determine timely filing. For institutional claims that include a span of service dates (i.e., a “from” and “through” date on the claim), the “through” date begins the count for the 365 days to determine timely filing. Any adjustments or corrections must also be received within the 365-day deadline.
Medicare/Medicaid Crossover claims must be submitted within six months from the date of Medicare payment stated on the Medicare Explanation of Medical Benefits (EOMB).
Medicare claims will “crossover” to Medicaid when an IHS provider is enrolled in the Utah Medicaid program. If a different NPI is used to bill Medicare than to bill Medicaid, contact the Medicaid provider enrollment team.
Do not send a claim if claims are crossing over from Medicare. Claims will pay Medicaid allowed (fee for service or AIR) minus TPL amount. Submit the claim to Medicaid the same as you submitted it to Medicare. For physician inpatient services that were paid line by line by Medicare, submit the claim to Utah Medicaid showing TPL line by line.
Updated July 2015