Utah Medicaid Provider Manual Indian Health
Division of Integrated Healthcare Updated May 2024
Section 2 Page 1 of 11
Section 2
Indian Health
Table of Contents
1 General Information......................................................................................................................... 2
1-1 General Policy .................................................................................................................................. 2
1-2 Fee-For-Service or Managed Care ..................................................................................................... 2
1-3 Definitions ........................................................................................................................................ 3
1-4 Procedure Codes ............................................................................................................................... 4
2 Provider Participation Requirements ................................................................................................ 4
2-1 Provider Enrollment .......................................................................................................................... 4
3 Member Eligibility .......................................................................................................................... 5
4 Program Coverage ........................................................................................................................... 5
4-1 Covered Services .............................................................................................................................. 5
5 Non-Covered Services and Limitations ............................................................................................ 5
5-1 Non-Covered Services ...................................................................................................................... 6
5-2 Limitations ....................................................................................................................................... 6
6 Billing ............................................................................................................................................. 8
6-1 Prior Authorization ........................................................................................................................... 9
6-2 Timely Filing .................................................................................................................................... 9
6-3 Medicaid/Medicare Crossovers ....................................................................................................... 10
7 References ..................................................................................................................................... 10
Utah Medicaid Provider Manual Indian Health
Division of Integrated Healthcare Updated May 2024
Section 2 Page 2 of 11
1 General Information
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.
1-1 General Policy
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.
1-2 Fee-For-Service or Managed Care
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
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Division of Integrated Healthcare Updated May 2024
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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 on the Eligibility Lookup
Tool: https://medicaid.utah.gov/eligibility.
1-3 Definitions
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 an 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
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Division of Integrated Healthcare Updated May 2024
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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).
1-4 Procedure Codes
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.
2 Provider Participation Requirements
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.
2-1 Provider Enrollment
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
• Meets all of the credential requirements as listed for each provider type.
• Completes the Utah Medicaid Provider application and signs the Utah Medicaid Provider agreement.
• Receives notice from the Utah Medicaid Program that the credentials have been met and the provider
agreement accepted.
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.
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Division of Integrated Healthcare Updated May 2024
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Hospital Services Requirements
An IHS hospital must be accredited according to Medicaid requirements.
3 Member Eligibility
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:
• Contact an I/T/U facility benefits coordinator.
• Go to www.jobs.utah.gov. Tribal members use the application ‘myCase’.
• Call DWS and speak to a worker:
o Call 1-866-435-7414; select option #1; enter the case number. (Once the case has been assigned
to the American Indian team, this selection will direct the call to a worker on the AI team.)
4 Program Coverage
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.
4-1 Covered Services
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.
5 Non-Covered Services and Limitations
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.
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Division of Integrated Healthcare Updated May 2024
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5-1 Non-Covered Services
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.)
• Durable medical equipment or medical supplies not generally provided during the course of a clinic visit
(i.e. diabetic supplies)
• Pharmaceutical or biologicals not generally provided during the clinic visit (i.e. medication samples)
• Other services that are not defined in the State Plan under Title XIX or Title XXI of the Social Security
Act
• Eyeglasses
• Emergency ambulance transportation
• Non-emergency transportation
• Prosthetic devices (other than dental) which replace all or part of an internal body organ (including
colostomy bags) and supplies directly related to colostomy care and the replacement of such devices
• Behavioral health rehabilitative services
• Hearing aids
• Behavioral health case management service
I/T/U services not reimbursable under outpatient encounters include:
• Health or group education classes or activities, including media productions and publications
• Vaccines covered by the Vaccines for Children (VFC) program
• Group or sports physicals and medical reports
• Medication samples or other prescription medications provided to the clinic free of charge
• Administrative medical examinations and report services
• Gauze, Band-Aids, or other disposable products used during an office visit
5-2 Limitations
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:
• Well child check and an immunization
• Preventive dental screen and fluoride varnish application in a single setting
• Medical encounter with a mental health or addiction diagnosis on the same day as a mental health or
addiction encounter
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• Mental health and addiction encounter with similar diagnosis
• Partial service with one medical provider and partial service from another medical provider
Abortion and Sterilization
Federal law governs these services.
• Abortion procedures are limited to those consistent with the Hyde Amendment restrictions. The
amendment allows the use of federal funds for abortions to terminate a pregnancy under two conditions:
o A pregnancy resulting from an act of rape or incest or
o The life of the mother would be endangered if the fetus were carried to term.
(42 CFR 441.203 and Public Law Number 105-78 Section 509 and 510, pertaining to revisions of
the Hyde Amendment, 1998).
• Sterilization procedures are limited to those procedures which meet the requirements of 42 CFR 441
Subpart F.
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.
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Division of Integrated Healthcare Updated May 2024
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Customer Service Hotline
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.
6 Billing
Refer to the provider manual, Section I: General Information, for detailed billing instructions.
Reimbursement
To receive the All-Inclusive Rate (AIR) reimbursement an I/T/U facility must have a current contract on file
with the Utah Department of Health and Human Services, Office of Healthcare Policy and Authorization.
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.
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Division of Integrated Healthcare Updated May 2024
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IHS and Tribal 638 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
Urban Indian Organizations are excluded from the above reimbursement types. UIOs are enrolled as Federally
Qualified Health Centers and reimbursed accordingly.
6-1 Prior Authorization
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.
• Medicaid Providers must verify whether PA is necessary, and comply with applicable requirements.
Failure to obtain prior authorization may result in a payment denial.
• I/T/U outpatient encounters for eligible AI/AN Utah Medicaid members whether medical, dental, or
behavioral health, are not subject to prior authorization.
• Abortion and sterilization procedures are governed by Federal law. Refer to Chapter 5-1, Limitations,
Abortion and Sterilization for details.
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.
6-2 Timely Filing
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).
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Division of Integrated Healthcare Updated May 2024
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6-3 Medicaid/Medicare Crossovers
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.
7 References
• 1905(b) of the Social Security Act, 42 U.S.C. 1396d
• 42 CFR 441 Subpart F
• 42 CFR 441.203 and
• Public Law Number 105-78 Section 509 and 510, pertaining to revisions of the Hyde Amendment, 1998
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