Medical, Dental & Pharmacy

Tribal and Federal Indian Health Services

PrimeWest Health American Indian members, living on or off a reservation, will have direct out-of-network access to Indian Health Service (IHS) facilities and facilities operated by a tribe or tribal organization under funding authorized by Title 25 United States Code (USC) Sections 450f– 450n, or Title III of the Indian Self-Determination and Education Assistance Act, Public Law Number 93-638 (Section 638 Facilities or Providers), for services that would otherwise be covered under MN Stat. sec. 256B.0625, even if such facilities are not participating providers. PrimeWest Health shall not require any Service Authorization or impose any condition for an American Indian to access services at such facilities.

The purpose of this chapter is to explain the policy, payment, and billing method for health care services provided through an IHS facility or a tribally owned facility funded by Title I or III of the Indian Self-Determination and Education Assistance Act (Public Law 93-638), as amended. In addition to the IHS- and tribal-specific policies and coverage, these facilities must also comply with all of the standard PrimeWest Health policies, coverage guidelines, and billing policies found in the PrimeWest Health Provider Manual.

Throughout this section, facilities of the Federal IHS will be referred to as “IHS facilities”; facilities operated by Federally recognized Indian tribes with Public Law 93-638 funding will be referred to as “tribal facilities.” Facilities operated by tribes that are not federally recognized should refer to Billing Requirements for payment and billing information.

Eligible Providers

To enroll as a PrimeWest Health provider, call the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free).

Tribal and IHS providers must meet the same service and licensure requirements as all other PrimeWest Health-enrolled providers, with the following exceptions:

  1. Federal employees providing health care services at IHS facilities are considered “licensable” and need not actually obtain a Minnesota license in order to be reimbursed
  2. Under MN Stat. sec. 256B.02, subd. 7, a Federally recognized Minnesota tribe may license or credential health care providers using standards adopted by its governing body. Providers credentialed this way may also enroll as PrimeWest Health providers.

The following list identifies occupations considered health professionals for purposes of billing IHS services (this is not an all-inclusive list):

  1. Advanced practice registered nurse (APRN)
  2. Certified registered nurse anesthetist (CRNA)
  3. Chiropractor
  4. Clinical nurse specialist (CNS)
  5. Clinical specialist in psychiatric and mental health nursing
  6. Counselor
  7. Dentist
  8. Dental hygienist
  9. Home health aide (HHA)
  10. Licensed clinical social worker
  11. Midwife
  12. Nurse practitioner (NP)
  13. Optometrist
  14. Personal care assistant (PCA)
  15. Physical therapist (PT)
  16. Physician
  17. Physician assistant (PA)
  18. Physician extender
  19. Podiatrist
  20. Psychologist
  21. Registered dietician
  22. Visiting nurse
     

Eligible Members

American Indians (AI) and Alaska Natives (AN) eligible for one of the PrimeWest Health programs are eligible for all covered services of the applicable PrimeWest Health program, even if they are also eligible for services provided through the IHS or tribal facilities.

Copay Limitations

The American Recovery and Reinvestment Act of 2009 (ARRA) prohibits the following providers from charging Minnesota Health Care Programs (MHCP) copays to American Indian recipients, regardless of whether or not the recipient is enrolled in a managed care organization (MCO):

  1. Tribal health care providers
  2. Federal IHS
  3. Urban Indian organizations
  4. IHS-contracted health services (CHS) when there is an IHS referral

Third Party Liability (TPL)

TPL coverage, including veterans’ benefits, private accident insurance, health maintenance organization (HMO) coverage, and other health care coverage held by or on behalf of a PrimeWest Health member is primary to PrimeWest Health except when the TPL is tribal insurance.