C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-9, subsec. 144-101-II-9.06
An Indian Health Center must bill using designated codes when providing Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services as described in Section 94 of the MaineCare Benefits Manual. EPSDT codes for use by Indian Health Center can be found at http://brightfutures.aap.org/pdfs/Coding%20for%20preventive%20care_1pdf.pdf .
The Indian Health Center must be enrolled as a provider under Section 94 of the MaineCare Benefits Manual and must follow all requirements outlined in that Chapter (including submission of the Bright Futures form) to bill under these codes. If the Indian Health Center provides EPSDT services and other medical services to the same individual as part of the same visit, the Center must bill only the EPSDT code. When immunizations are provided, the appropriate immunization and administration codes shall be noted on the CMS-1500 billing form, but no additional reimbursement shall be available. Diabetes education and asthma self-management shall also be billed using distinct codes found at http://maa.dshs.wa.gov/download/Memos/2002Memos/02-61maa%20Asthma-Diabetes.pdf .
A second, same day visit may be billed if it is medically necessary and could not have been anticipated by the Center's professional staff as documented in the members' record or when the first encounter is a medical visit and a second visit is a mental health visit. Billing codes for additional, same day visits must incorporate the appropriate code and/or modifier.
In order to ensure appropriate federal financial participation, non-tribal members must be identified on the CMS 1500 claim form.
Indian Health Centers have the option of obtaining a separate National Provider Identification (NPI) number for the limited purpose of fee-for-service billing and reimbursement for pharmacy, ambulance or any other ambulatory services in the State's Medicaid Plan, not covered under this Section. Such services must be provided in accordance with all applicable sections of the MaineCare Benefits Manual and will be reimbursed in accordance with those sections.
Indian Health Centers may choose to enroll as Federally Qualified Health Centers (FQHCs) or Ambulatory Care Clinics. For purposes of billing Medicaid, each center may choose only one designation. Centers may remain FQHCs for the purposes of billing Medicare, while enrolling as Ambulatory Care Clinics under Medicaid. If permitted by a ruling from federal authorities, Indian Health Centers may bill retroactively as Ambulatory Care Clinics as allowed under that ruling. As a condition of enrollment Indian Health Centers must provide a copy of their contract with the Indian Health Services.
Section 5006(a) of the American Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law 111-5 amends sections 1916 and 1916A of the Social Security Act, to preclude States from imposing Medicaid premiums or any other Medicaid cost sharing on Indian applicants and members served by Indian health providers and to assure that Indian health providers and providers of contract health services (CHS) under a referral from an Indian health provider, will receive full payment. A tribal member who is presently or has previously been eligible for CHS or to receive services through an I/T/U will be exempt from co-payments (onetime documentation is necessary to provide proof of present or previous I/T/U or CHS eligibility).
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-9, subsec. 144-101-II-9.06