Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 11 - INDIAN HEALTH SERVICE (IHS) FACILITIES › Section 471-11-004 - BILLING AND PAYMENT FOR IHS OR TRIBAL (638) FACILITY SERVICES

Current through June 17, 2024
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; and
b. 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 list
11-004.01B4 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.