Indian Health Services

The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives.

Enrollment

To enable direct billing of DMEPOS, an Indian Health Service (IHS) facility must enroll with the National Supplier Clearinghouse (NSC) and secure a Medicare supplier billing number. For enrollment purposes, Medicare recognizes two types of IHS facilities:

  • Those facilities wholly owned and operated by the IHS; and
  • Facilities that are owned by the IHS, but tribally operated or totally owned and operated by a tribe.

To enroll, the IHS facility must complete the Medicare Enrollment Application for DMEPOS Suppliers, CMS-855S. The CMS-855S must be completed in accordance with its associated instructions, except as follows:

  • Facilities totally owned and operated by the IHS are considered a governmental organization. An Area Director of the IHS must sign the Section 15 Certification Statement of the CMS-855S, be listed in Section 6 of the form and sign the letter required by Section 5 of the form, which attests the IHS will be legally and financially responsible in the event there is any outstanding debt owed to CMS.
  • Facilities tribally operated are considered tribal organizations. The Section 15 Certification Statement of the CMS-855S must be signed by a tribal official who meets the definition of an authorized official in accordance with the page 2 definitions shown on the CMS-855S. The same authorized official must be listed in Section 6 of the CMS-855S and must sign the letter required by Section 5 of the form which attests the tribe will be legally and financially responsible in the event there is any outstanding debt owed to CMS.

Facility Requirements

IHS facility requirements include the following:

  • Site visits will be required for all IHS facilities enrolling for DMEPOS. This includes all hospitals and pharmacies. All IHS facilities enrolled by the NSC must meet all required standards as verified by the review procedures for all other DMEPOS suppliers except as discussed in this chapter.
  • All IHS facilities, whether operated by the IHS or a tribe, must be exempt from the comprehensive liability insurance requirements under 42 CFR Sec. 424.57(c)(10).
  • All IHS facilities, whether operated by the IHS or a tribe, will be exempt from the requirement to provide any state licenses for their facility/business. For example, if the DMEPOS supplier indicates on its application that it will be providing hospital beds and is located in a state that requires a bedding license, such licensure is not required for Medicare enrollment. However, if they provide a DMEPOS item that requires a licensed professional in order to properly provide the item, the IHS facility must provide a copy of the professional license. The licensed professional can be licensed in any state or have a federal license. For example, a pharmacy does not need a pharmacy license, but must have a licensed pharmacist.

Assignment of Specialty Codes and Appropriate Billing

Upon successful enrollment, the NSC will provide identifiers identifying IHS enrollments and IHS hospitals in order to facilitate proper reimbursement. The NSC will enroll all IHS facilities including all hospitals and clinics (free standing or hospital based). This includes all facilities whether wholly owned and operated by the IHS or tribally owned and/or operated. For any IHS facility that enrolls, the NSC will issue a supplier number with:

  • An A9 specialty code for newly enrolled IHS DMEPOS suppliers which are not hospitals; or
  • An A9/A0 specialty code for newly enrolled IHS DMEPOS suppliers which are IHS/tribal hospitals and hospital based facilities to include Critical Access Hospitals (CAHs).

The specialty indicator will ensure the claims are paid appropriately by either the Fiscal Intermediary (FI) or DME MAC. IHS facilities with a specialty code of A9/A0 must submit claims for prosthetics, orthotics and surgical dressings to their Medicare FI for payment and not to a DME MAC.

Guidelines

IHS suppliers may submit claims to Noridian (Jurisdiction D DME MAC), or to the appropriate DME MAC that has jurisdiction for the claim, for the following DMEPOS services:

  • Durable medical equipment
  • Prosthetics
  • Orthotics
  • Surgical dressings
  • Therapeutic shoes
  • Drugs (those normally billed to DME MACs)

IHS, tribe and tribal organization facilities, may submit claims for the following services to TrailBlazer Health Enterprises:

  • Splints
  • Casts
  • Clinical laboratory services
  • Ambulance services
  • Drugs (those normally billed under Part B)

IHS, tribe and tribal organization facilities providing DMEPOS services must enroll as a DME supplier with the NSC (see "Enrollment" section above).

Payment for DMEPOS claims, including durable medical equipment, prosthetics, orthotics, prosthetic devices, surgical dressings and therapeutic shoes, will be based upon the appropriate fee schedule based upon the beneficiary's address.

Claims

DME MACs will apply current edits to IHS claims. Important information regarding claim submission, coverage and documentation is available in this manual.

Claims received from an outpatient (freestanding) clinic operated by the IHS containing an item/service that is not covered in this instruction, such as end stage renal disease (ESRD) supplies, will be denied with reason code 96 (non-covered charges).

Claims received from an outpatient (freestanding) clinic operated by the IHS with a date of service prior to January 1, 2005, will be denied with reason code 26 (expenses incurred prior to coverage).

All IHS claims will be processed as assigned, even if submitted by the IHS supplier as non-assigned. For additional information on accepting assignment, view the Participating/Non-participating section of Noridian's Enrollment webpage.

Although Medicare applies deductible and coinsurance amounts, these amounts are waived by the IHS.

 

Last Updated Feb 11, 2020