CMS Technical Instructions: Reporting T-MSIS Data Pursuant to SHO #16-002 (Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives) (Special Programs)

Technical Instruction History

Date	Description of Change
07/25/2017	Original technical instructions issued
06/24/2022	Technical instructions updated in correspondence with the V3.0.0 data dictionary update: Added the data element IHS-SERVICE-IND (CIP296, CLT243, COT234, CRX172) Renamed the data element AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR (ELG215) (formerly known as CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR)

Brief Issue Description

On February 26, 2016, CMCS issued a State Health Official (SHO) letter, SHO #16-002, to inform state Medicaid agencies and other state health officials about an update in payment policy affecting federal funding for services received by Medicaid-eligible individuals, who are American Indians and Alaska Natives (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. The SHO letter explained the requirements necessary to allow amounts paid by the State to be eligible for the enhanced federal matching authorized under section 1905(b) of the Social Security Act at a rate of 100 percent. 

To support the evaluation of this payment policy using T-MSIS data, it is necessary to report relevant T-MSIS data elements in accordance with the SHO letter. The SHO letter (PDF, 128.37 KB), FAQs (PDF, 185.8 KB) related to the SHO letter and the T-MSIS data dictionary are located on Medicaid.gov.

Instructions contained in the current T-MSIS Data Dictionary are outdated and are scheduled for updating in the next release of the data dictionary. The CMS technical instructions below supersedes the current definitions and coding requirements and should be followed.

CMS Technical Instruction

If a state plans to request reimbursement consistent with the SHO letter, its coding of T-MSIS files should comply with the technical instructions below.

Required ENROLLEE Information

For each AI/AN Medicaid beneficiary for whom the state plans to request reimbursement consistent with the SHO letter, the state must include in its eligibility file a RACE-INFORMATION record segment (ELG00016) with Data Element # ELG215 populated with valid value “1” (Individual meets the definition of an American Indian/Alaska Native).

Data Element # ELG215 is the AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR field.

Note that the former name for Data Element # ELG215 in the T-MSIS data dictionary is “CERTIFIED-AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR.” This data element was renamed “AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR” in the T-MSIS Data Dictionary V3.0.0.

Definition of AMERICAN INDIAN OR ALASKA NATIVE:

"American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR § 136.12. This means the individual:

1. Is a member of a Federally-recognized Indian tribe;
2. Resides in an urban center and meets one or more of the following four criteria:
   1. Is 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, of any such member;
   2. Is an Eskimo or Aleut or other Alaska Native;
   3. Is considered by the Secretary of the Interior to be an Indian for any purpose; or
   4. Is determined to be an Indian under regulations promulgated by the Secretary of Health and Human Services;
3. Is considered by the Secretary of the Interior to be an Indian for any purpose; or
4. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native.

Valid Values for the AMERICAN–INDIAN/ALASKA-NATIVE INDICATOR:

The value chosen for the T-MSIS American Indian/Alaska Native Indicator should reflect answers provided by applicants who complete Appendix B of the Marketplace/Medicaid application, which asks the following questions:

1. Are you a member of a federally recognized tribe?
2. Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?

Valid values for Data Element # ELG215 are:

0 = Individual does not meet the definition of an American Indian/Alaska Native.

1 = Individual meets the definition of an American Indian/Alaska Native.

Required PROVIDER Information

In the T-MSIS Provider File, the state must include the following:

Provider File Records

1. Each IHS facility (i.e., hospitals, clinics, FQHCs and nursing facilities) and Tribal facility¹ (i.e., Tribe-operated hospitals, clinics, FQHCs and nursing facilities) needs to have a record in the Provider File.
2. Each specialist and other non-IHS/Tribal provider² needs to have a record in the Provider File.

Written Care Coordination Arrangements

1. A “written care coordination arrangement” between the IHS/Tribal hospital or clinic and each specialist or other non-IHS/Tribal provider must exist.

T-MSIS PROV-AFFILIATED-GROUPS record segments

1. For each of the written care coordination arrangement relationships, a T-MSIS PROV-AFFILIATED-GROUPS record segment (PRV00008) must be created.  To clarify, the information being collected:
   1. SUBMITTING-STATE-PROV-ID = the ID of the specialist or other non-IHS/Tribal provider
   2. SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY = the ID of the hospital, clinic, FQHC, or nursing facility with whom the provider has a written care coordination arrangement
   3. PROV-AFFILIATED-GROUP-EFF-DATE = the date that the written care coordination arrangement becomes effective
   4. PROV-AFFILIATED-GROUP-END-DATE = the date that the written care coordination arrangement ceases to be in effect (If the care coordination agreement is open-ended – i.e., no specific end date – the state should enter 99991231.)

Required CLAIM Information

In the T-MSIS Claims Files, the state must include the following:

Billing Provider Identifiers

1. On Claim-IP, Claim-LT, Claim-OT & Claim-RX:
   1. BILLING-PROV-NUM
   2. BILLING-PROV-NPI-NUM

Referring Provider Identifiers

1. On Claim-IP, Claim-LT, Claim-OT:
   1. REFERRING-PROV-NPI-NUM
   2. REFERRING-PROV-NUM
2. On Claim-RX:
   1. PRESCRIBING-PROV-NPI-NUM
   2. PRESCRIBING-PROV-NUM

Rendering Provider Identifiers

1. On Claim-IP, Claim-LT, Claim-OT:
   1. SERVICING-PROV-NPI-NUM
   2. SERVICING-PROV-NUM
2. On Claim-RX:
   1. DISPENSING-PRESCRIPTION-DRUG-PROV-NPI
   2. DISPENSING-PRESCRIPTION-DRUG-PROV-NUM

Referral Numbers

1. On Claim-IP, Claim-LT, Claim-OT & Claim-RX:
   1. PRE-AUTHORIZATION-NUM

Indian Health Service (IHS) Indicator

1. On Claim-IP, Claim-LT, Claim-OT & Claim-RX:
   1. IHS-SERVICE-IND
   2. (To capture Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes, as of T-MSIS Data Dictionary V3.0.0 a new data element, IHS-SERVICE-IND, was added.)

Dates of Service

1. On Claim-IP, Claim-LT, Claim-OT:
2. 1. BEGINNING-DATE-OF-SERVICE
   2. ENDING-DATE-OF-SERVICE
      
      (CMS would expect the BEGINNING-DATE-OF-SERVICE to fall between PROV-AFFILIATED-GROUP-EFF-DATE and PROV-AFFILIATED-GROUP-END-DATE) and (ENDING-DATE-OF-SERVICE to fall between PROV-AFFILIATED-GROUP-EFF-DATE and PROV-AFFILIATED-GROUP-END-DATE)

Date Prescribed

1. On Claim-RX:
2. 1. DATE-PRESCRIBED
      
      (CMS would expect the DATE-PRESCRIBED to fall between PROV-AFFILIATED-GROUP-EFF-DATE and PROV-AFFILIATED-GROUP-END-DATE)