Tribal 638 Manual
Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
If you experience any difficulty opening a section or link from this page, please email the webmaster.
How to Search this manual:
This manual has 3 search options.
- Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
- Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
- Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.
Prior manuals may be located through the provider website archives.
Updated 07/26/2023
Complete Tribal 638 Provider Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes all previous Montana Healthcare Programs IHS/Tribal 638 Provider Manuals posted on the IHS webpage. Published by the Montana Department of Public Health & Human Services, July 2023.
Update Log
07/26/2023
• New provider manual developed.
End of Update Log Chapter
Table of Contents
Key Contacts
Introduction
Covered Services
• Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201-2235)
Non-Covered Services (ARM 37.85.207 and 37.86.3002)
Importance of Fee Schedules
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment is Calculated
Tribal 638 Rates
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS Tribal 638 Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Montana Tribal Health Departments
| Tribal Health Department | Address | Main Telephone Number | Fax Number |
| Blackfeet Nation | Blackfeet Nation Health Services PO Box 850 Browning, MT 59417 |
(406) 338-7521 |
(406) 338-6311 |
| Chippewa Cree Tribe | Rocky Boy Health Center 6850 Upper Box Elder Road Box Elder, MT 59521 |
(406) 395-4486 | (406) 395-4408 |
| Confederated Salish and Kootenai Tribes | Confederated Salish and Kootenai Tribal Health Department PO Box 880 St. Ignatius, MT 59865 |
(406) 745-3525 |
(406) 745-4231 |
| Crow Tribe | Crow Tribal Health Department PO BOX 159 Crow Agency, MT 59022 |
(406) 998-4782 | (406) 353-2884 |
| Fort Belknap Tribes | Fort Belknap Tribal Health Department 656 Agency Main Street Harlem, MT 59526 |
(406) 353-8323 | (406) 768-5780 |
| Fort Peck Tribes | Fort Peck Tribal Health Department PO Box 1027 Poplar, MT 59255 |
(406) 768-5790 | (406) 315-2401 |
| Little Shell Chippewa | Little Shell Tribal Health Department 615 Central Ave West Great Falls, MT 59404 |
(406) 315-2400 | (406) 315-2401 |
| Northern Cheyenne Tribe | Northern Cheyenne Board of Health PO Box 67 Lame Deer, MT 59043 |
(406) 477-6722 | (406) 477-6829 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638 Health Services. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the Provider Information website. Providers are asked to review both manuals.
A table of contents outlines the chapters in this manual. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. Choose the Contact Us option under the ARM menu across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Tribal 638 program:
- Code of Federal Regulations (CFR)
- 42 CFR Part 136 and 136A
- Montana Code Annotated (MCA)
- MCA 53-6-101
- Administrative Rules of Montana (ARM)
- ARM 37.82.101
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying providers’ claims as quickly as possible. Claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Getting Questions Answered
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. Manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
Covered Services
General Coverage Principles
This chapter provides covered services information that applies specifically to Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638. Services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Provider Requirements (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
Tribal 638 providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physician’s current license from another state would satisfy this requirement.
Additional information for Physician requirements are available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at a Tribal 638 facility are not eligible to enroll with Montana Healthcare Programs.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children aged 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:
- Nutritionist services
- Private duty nursing
- Respiratory therapy
- Therapeutic family and group home care
- School-based services
All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers Manual.
Coverage of Specific Services
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and Tribal 638 as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for Tribal 638 services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers manual.
Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (the majority of the services operating under 638 authorities are under the Tribal 638 Fee Schedule). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter.
Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are also available on the Provider Information website.
End of Covered Services Chapter
Passport to Health Program
What Is Passport to Health? (ARM 37.86.5101–5120)
Passport to Health is the managed care program for Montana Medicaid members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Tribal 638
Members who are eligible for both Tribal 638 Services and Montana Medicaid may choose a Tribal 638 provider or another provider as their Passport provider. Members who are eligible for Tribal 638 Services do not need a referral from their Passport provider to obtain services from Tribal 638 Facilities. If a Tribal 638 provider refers the member to a non-Tribal 638 provider or specialist, a Passport or Team Care referral is not needed.
Refer to Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website; lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed.
- PA criteria for most services are available on the Provider Information website.
- If a service requires prior PA, the requirements exist for all members. PA is usually obtained through the Department or a PA contractor.
- For prior authorization criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information website.
Services will not be reimbursed when PA requirements are not met. See the Prior Authorization Information link in the left menu on the Provider Information website.
End of Prior Authorization Chapter
Coordination of Benefits (COB)
End of Coordination of Benefits Chapter
Billing Procedures
Claim Forms
Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Member Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed.
Tribal 638 Revenue Codes
Tribal 638 providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) is required for some services. Passport and PA are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers Manual.)
Some services provided by a Tribal 638 provider are billed with the Tribal 638 provider number and codes specific to Tribal 638. Other services require the Tribal 638 provider to enroll as a Montana Healthcare Programs provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for services must indicate the provider of service. Claims for services rendered in Tribal 638 facilities are submitted using the Tribal 638 facility’s provider number.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dental | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider * Tribes who have 638 approval for Dialysis services receive reimbursement at the current all-inclusive rate. |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| EPSDT (children aged 20 and under) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Eyeglasses Dispensing | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. |
HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Laboratory | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
|
Licensed Professional Counselor |
Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Medical/Surgical Supplies | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Optical Exam | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Clinic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Surgery | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Podiatry | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology, Diagnostic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Speech Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Telemedicine | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
For information on remittance advices and adjustments, see the General Information for Providers Manual, available on the website. (Link once Provider Type 81 page is active)
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
Tribal 638 Rates
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Tribal 638 facilities are operated according to the Medicaid State Plan and reflected in the current fee schedule. Unless otherwise stated, the payment methodology follows IHS facility reimbursement which is paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services as set forth in the Federal Register. Payment adjustments are made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Appendix C: Search Options
This manual has three search options;
1. Search the whole manual.
Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by chapter.
Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site search.
Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.
End of Search Options Chapter
End of Tribal 638 Provider Manual
Update Log
Publication History
This publication supersedes all previous Montana Healthcare Programs IHS/Tribal 638 Provider Manuals posted on the IHS webpage. Published by the Montana Department of Public Health & Human Services, July 2023.
Update Log
07/26/2023
• New provider manual developed.
End of Update Log Chapter
Table of Contents
Key Contacts
Introduction
Covered Services
• Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201-2235)
Non-Covered Services (ARM 37.85.207 and 37.86.3002)
Importance of Fee Schedules
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment is Calculated
Tribal 638 Rates
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS Tribal 638 Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Montana Tribal Health Departments
| Tribal Health Department | Address | Main Telephone Number | Fax Number |
| Blackfeet Nation | Blackfeet Nation Health Services PO Box 850 Browning, MT 59417 |
(406) 338-7521 |
(406) 338-6311 |
| Chippewa Cree Tribe | Rocky Boy Health Center 6850 Upper Box Elder Road Box Elder, MT 59521 |
(406) 395-4486 | (406) 395-4408 |
| Confederated Salish and Kootenai Tribes | Confederated Salish and Kootenai Tribal Health Department PO Box 880 St. Ignatius, MT 59865 |
(406) 745-3525 |
(406) 745-4231 |
| Crow Tribe | Crow Tribal Health Department PO BOX 159 Crow Agency, MT 59022 |
(406) 998-4782 | (406) 353-2884 |
| Fort Belknap Tribes | Fort Belknap Tribal Health Department 656 Agency Main Street Harlem, MT 59526 |
(406) 353-8323 | (406) 768-5780 |
| Fort Peck Tribes | Fort Peck Tribal Health Department PO Box 1027 Poplar, MT 59255 |
(406) 768-5790 | (406) 315-2401 |
| Little Shell Chippewa | Little Shell Tribal Health Department 615 Central Ave West Great Falls, MT 59404 |
(406) 315-2400 | (406) 315-2401 |
| Northern Cheyenne Tribe | Northern Cheyenne Board of Health PO Box 67 Lame Deer, MT 59043 |
(406) 477-6722 | (406) 477-6829 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638 Health Services. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the Provider Information website. Providers are asked to review both manuals.
A table of contents outlines the chapters in this manual. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. Choose the Contact Us option under the ARM menu across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Tribal 638 program:
- Code of Federal Regulations (CFR)
- 42 CFR Part 136 and 136A
- Montana Code Annotated (MCA)
- MCA 53-6-101
- Administrative Rules of Montana (ARM)
- ARM 37.82.101
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying providers’ claims as quickly as possible. Claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Getting Questions Answered
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. Manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
Covered Services
General Coverage Principles
This chapter provides covered services information that applies specifically to Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638. Services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Provider Requirements (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
Tribal 638 providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physician’s current license from another state would satisfy this requirement.
Additional information for Physician requirements are available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at a Tribal 638 facility are not eligible to enroll with Montana Healthcare Programs.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children aged 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:
- Nutritionist services
- Private duty nursing
- Respiratory therapy
- Therapeutic family and group home care
- School-based services
All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers Manual.
Coverage of Specific Services
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and Tribal 638 as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for Tribal 638 services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers manual.
Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (the majority of the services operating under 638 authorities are under the Tribal 638 Fee Schedule). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter.
Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are also available on the Provider Information website.
End of Covered Services Chapter
Passport to Health Program
What Is Passport to Health? (ARM 37.86.5101–5120)
Passport to Health is the managed care program for Montana Medicaid members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Tribal 638
Members who are eligible for both Tribal 638 Services and Montana Medicaid may choose a Tribal 638 provider or another provider as their Passport provider. Members who are eligible for Tribal 638 Services do not need a referral from their Passport provider to obtain services from Tribal 638 Facilities. If a Tribal 638 provider refers the member to a non-Tribal 638 provider or specialist, a Passport or Team Care referral is not needed.
Refer to Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website; lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed.
- PA criteria for most services are available on the Provider Information website.
- If a service requires prior PA, the requirements exist for all members. PA is usually obtained through the Department or a PA contractor.
- For prior authorization criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information website.
Services will not be reimbursed when PA requirements are not met. See the Prior Authorization Information link in the left menu on the Provider Information website.
End of Prior Authorization Chapter
Coordination of Benefits (COB)
End of Coordination of Benefits Chapter
Billing Procedures
Claim Forms
Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Member Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed.
Tribal 638 Revenue Codes
Tribal 638 providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) is required for some services. Passport and PA are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers Manual.)
Some services provided by a Tribal 638 provider are billed with the Tribal 638 provider number and codes specific to Tribal 638. Other services require the Tribal 638 provider to enroll as a Montana Healthcare Programs provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for services must indicate the provider of service. Claims for services rendered in Tribal 638 facilities are submitted using the Tribal 638 facility’s provider number.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dental | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider * Tribes who have 638 approval for Dialysis services receive reimbursement at the current all-inclusive rate. |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| EPSDT (children aged 20 and under) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Eyeglasses Dispensing | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. |
HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Laboratory | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
|
Licensed Professional Counselor |
Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Medical/Surgical Supplies | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Optical Exam | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Clinic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Surgery | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Podiatry | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology, Diagnostic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Speech Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Telemedicine | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
For information on remittance advices and adjustments, see the General Information for Providers Manual, available on the website. (Link once Provider Type 81 page is active)
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
Tribal 638 Rates
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Tribal 638 facilities are operated according to the Medicaid State Plan and reflected in the current fee schedule. Unless otherwise stated, the payment methodology follows IHS facility reimbursement which is paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services as set forth in the Federal Register. Payment adjustments are made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Appendix C: Search Options
This manual has three search options;
1. Search the whole manual.
Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by chapter.
Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site search.
Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.