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)

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 v4.0.0 T-MSIS data dictionary located within the T-MSIS Data Guide.

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.

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, AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR, populated with valid value “1” (Individual meets the definition of an American Indian/Alaska Native).

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 another Alaska Native;
   3. Is considered by the Secretary of the Interior to be an Indian for any purpose;
   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.

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 is as follows:
   1. SUBMITTING-STATE-PROV-ID: The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System.
   2. SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY: The unique, state-assigned identification number for the group or subpart with which the individual or subpart is associated. (The submitting state's unique identifier for the group. (Note: The group will also be in the provider data set as a provider (i.e., the group-as-a-provider).
   3. PROV-AFFILIATED-GROUP-EFF-DATE: The first calendar day on which all of the other data elements in the same segment were effective.
   4. PROV-AFFILIATED-GROUP-END-DATE: The last calendar day on which all of the other data elements in the same segment were effective. If the care coordination agreement is open-ended – i.e., no specific end date – the state should enter 99991231.

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 at the header level:
   1. BILLING-PROV-NUM (IP, LT, OT, RX)
   2. BILLING-PROV-NPI-NUM (IP,LT, OT, RX)
2. On Claim-IP, Claim-LT, Claim-OT at the header level:
   1. BILLING-PROV-ADDR-LN-1 (IP, LT, OT)
   2. BILLING-PROV-ADDR-LN-2 (IP, LT, OT)
   3. BILLING-PROV -CITY (IP, LT, OT)
   4. BILLING-PROV -STATE (IP, LT, OT)
   5. BILLING-PROV -ZIP-CODE (IP, LT, OT)

Referring Provider Identifiers

1. On Claim-IP, Claim-LT, Claim-OT at both header and line levels: =
   1. REFERRING-PROV-NPI-NUM
   2. REFERRING-PROV-NUM
2. On Claim-RX at the header level:
   1. PRESCRIBING-PROV-NPI-NUM
   2. PRESCRIBING-PROV-NUM
3. On Claim-OT at the header and line level:
   1. REFERRING-PROV-NPI-NUM-2

Rendering Provider Identifiers

1. On Claim-IP, Claim-LT, Claim-OT at the line level:
   1. SERVICING-PROV-NPI-NUM
   2. SERVICING-PROV-NUM
2. On Claim-RX at header level:
   1. DISPENSING-PRESCRIPTION-DRUG-PROV-NPI
   2. DISPENSING-PRESCRIPTION-DRUG-PROV-NUM

Referral Numbers

1. On Claim-IP, Claim-LT, Claim-OT & Claim-RX at the line level:
   1. PRE-AUTHORIZATION-NUM

Indian Health Service (IHS) Indicator

1. On Claim-IP, Claim-LT, Claim-OT & Claim-RX:
   1. IHS-SERVICE-IND (line level): To indicate 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. As of T-MSIS Data Dictionary V4.0.0, this data element is now mandatory and must be populated with a valid value.)

Dates of Service

1. On Claim-IP, Claim-LT, Claim-OT at the header and line level:
   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 at the header level:
   1. DATE-PRESCRIBED
      
      (CMS would expect the DATE-PRESCRIBED to fall between PROV-AFFILIATED-GROUP-EFF-DATE and PROV-AFFILIATED-GROUP-END-DATE)