Section 471-11-004 - BILLING AND PAYMENT FOR IHS OR TRIBAL (638) FACILITY SERVICES The hospital-based facility shall submit all claims for payment for services to Medicaid clients on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). Non-hospital-based providers shall use the appropriate-claim form or electronic format (see Claim Submission Table at 471-000-49).
The Indian Health Service shall bill all outpatient charges provided on the same day for the same Medicaid client as one outpatient charge per day.
All IHS facility claims for payment are subject to appropriate claim edits and to surveillance and utilization review upon entry into the claims processing system. The hospital utilization review abstract/summary may be requested by Medicaid Division staff.
004.01 Billing 11-004.01A General Billing Requirements Providers shall comply with all applicable billing requirements codified in 471 NAC Chapter 3. In the event that individual billing requirements in 471 NAC Chapter 3 conflict with billing requirements outlined in this 471 NAC Chapter 11, the individual billing requirements in 471 NAC Chapter 11 shall govern.11-004.01B Specific Billing Requirements: The hospital-based facility shall submit all claims for payment for services to Medicaid clients on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). Non-hospital-based providers shall use the appropriate claim form or electronic format (see Claim Submission Table at Appendix 471-000-49). All IHS Providers shall comply with applicable billing instructions in Appendix 471-000-62. 11-004.01B1 Non-Encounter Charges: IHS Providers may provide services outside of those that meet encounter criteria. Services covered by Medicaid, but not considered eligible for encounter reimbursement, are to be billed on Form CMS-1500 using the appropriate HCPCS codes and will be paid according to the Nebraska Practitioner Fee Schedule.11-004.01B2 Outpatient Encounter Charges: The Indian Health Service shall bill all outpatient encounter charges provided on the same day for the same Medicaid client as one outpatient charge per day.11-004.01B3 Inpatient Charges: The Inpatient hospital per diem rate for inpatient medical care provided by IHS facilities is published annually in the Federal Register or Federal Register Notices. In order to receive the inpatient hospital per diem rate, the IHS or Tribal 638 facility must: a. Be enrolled as a provider with Medicaid; andb. Appear on the IHS maintained listing of IHS-operated facilities and Indian health care facilities operating under a 638 agreement. It is the sole responsibility of the facility to petition IHS for placement on this list11-004.01B4 Utilization Review: All IHS Provider claims for payment are subject to appropriate claim edits and to surveillance and utilization review upon entry into the claims processing system. The hospital utilization review abstract/summary may be requested by Department staff.004.02 Payment 11-004.02A General Payment Requirements Nebraska Medicaid will reimburse the Provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC Chapter 3. In the event that individual payment regulations in 471 NAC Chapter 3 conflict with payment regulations outlined in this 471 NAC Chapter 11, the individual payment regulations in 471 NAC Chapter 11 shall govern.11-004.02B Specific Payment Requirements: 11-004.02B1 Reimbursement: IHS or Tribal (638) facilities will be paid at the most current encounter rate established by the IHS which is published annually in the Federal Register for established services provided in a facility that would ordinarily be covered services through the Nebraska Medicaid Program. Medicaid reimburses IHS facilities for inpatient and outpatient services at the Medicare/Medicaid rates established by the federal Department of Health and Human Services (DHHS).11-004.02B2 Rate Methodology: Rate changes are effective the first day of the month following the Department's receipt of the Medicare Interim Rate Notice, and will be applied retroactively to the federal effective date. Because specific Medicare/Medicaid rates are used and there is 100 percent federal match of these costs, Medicaid will not make an end-of-year settlement for Indian Health Service facilities.471 Neb. Admin. Code, ch. 11, § 004