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24-423m Know Your Rights and Protections as a Provider Serving American Indian Members

Date: 05/06/24

All Plan Letter 24-002 clarifies health plan requirements that affect provider contracting, claims reimbursement and tribal liaison responsibilities

On February 8, 2024, the California Department of Health Care Services (DHCS) released All Plan Letter (APL) 24-002, Medi-Cal Managed Care Plan Responsibilities for Indian Health Care Providers and American Indian Members (PDF). The APL affects Indian health care providers (IHCPs), which include health care programs operated by the Indian Health Service, an Indian tribe, a tribal organization or an urban Indian organization.1

Topics impacting IHCPs include, but are not limited to:

  • Rights and protections for IHCPs, including requirements for the Plan related to contracting with IHCPs and reimbursing claims from IHCPs in a timely and expeditious manner.
  • Guidance regarding the Plan’s tribal liaison requirements and expectations in relation to their role and responsibilities. Liaisons can aid IHCPs through provider relations services, claims/payment assistance and resolution, and member services.

Your rights and protections

Existing rights and protections for IHCPs, on the topics of enrollment, contracting, credentialing and site review, and claims payment include, but aren’t limited to areas such as:

Provider enrollment

Current policy allows providers to enroll through either the state-level enrollment pathway or the Plan enrollment pathway. However, an IHCP facility must enroll through the state-level enrollment pathway to receive reimbursement at the All-Inclusive Rate or Prospective Payment System, and to receive Medi-Cal fee-for-service reimbursement for Plan carved-out services, such as dental services.

Ordering, Referring and Prescribing provider enrollment

Individual practitioners who provide services at an IHCP facility are enrolled in Medi-Cal as an Ordering, Referring, and Prescribing provider.

Contracting

  • IHCPs do not have to contract with the Plan as a network provider, nor do IHCPs have to contract with any Plan subcontractor to be reimbursed by either the Plan or the subcontractor for services provided to an American Indian Plan member.
  • IHCPs cannot be required to obtain or maintain insurance (including professional liability insurance), provide indemnification or guarantee that the Plan will be held harmless from liability.
  • The IHCP shall not be required to submit any disputes between the parties to binding arbitration, notwithstanding any provision in the Plan’s contract with an IHCP.
  • To the extent the Plan imposes any medical quality assurance requirements on its network IHCPs, any such requirements applicable to the IHCP are subject to Section 805 of the Indian Health Care Improvement Act.
  • Nothing in the Plan’s contract with an IHCP, or in any addendum thereto, can constitute a waiver of federal or tribal sovereign immunity.

Credentialing and recredentialing

The Plan is required to conduct site reviews of contracted IHCPs that are primary care physicians (PCPs).

Claims payment

The IHCP does not need to have a contract with the Plan to receive reimbursement for services provided to an American Indian member of the Plan.

The Plan must pay claims from the IHCP at either the rate provided under the California Medicaid State Plan in a fee-for-service payment methodology or the applicable encounter rate published each year in the Federal Register by the IHS, whichever is higher; or at the providers established Prospective Payment System rate. Tribal Health Programs are to be reimbursed at the federally established All-Inclusive Rate as noted in APLs 17-020 and 21-008. Urban Indian Organizations, enrolled in Medi-Cal as a Federally Qualified Health Center, are to be reimbursed through the Prospective Payment System methodology.

The Plan must reimburse IHCPs that provide covered services in a timely and expeditious manner. The tribal liaison can assist IHCPs in addressing claims and payment inquiries.

Transportation reimbursement

The Plan must reimburse IHCPs for transporting an American Indian Plan member to an IHCP. If the IHCP is providing covered services to an American Indian member, including transportation, the IHCP must be enrolled in the Medi-Cal program through a state-level enrollment pathway. The IHCP is not required to be contracted with the Plan to be reimbursed for services. If the Plan subcontracts with an entity to provide services, such as  transportation, the IHCP is also not required to contract with the Subcontractor to bill. Either the Plan or the subcontractor would be required to reimburse the IHCP.

If an IHCP wishes to provide transportation services to non-American Indian Plan members, the IHCP must be enrolled in the Medi-Cal program as a transportation provider and must contract with the Plan and/or the Plan’s delegated transportation provider.

Member rights that may affect you

APL 24-002 describes several American Indian member rights and protections that relate to physicians and other providers:

  • An American Indian member can request to receive services from an IHCP and choose an IHCP within the Plan’s network as a PCP.
  • An American Indian member can also obtain covered services from an out-of-network IHCP without requiring a referral from a network PCP or prior authorization.
  • IHCPs, whether in the Plan’s network or out-of-network, can provide referrals directly to network providers without a referral from a network PCP or prior authorization. An American Indian member may receive services from an out-of-network IHCP even if there are in-network IHCPs available. When an American Indian Plan member requests to receive services from an IHCP and there is no in-network IHCP available, then the Plan must assist the member in locating and connecting with an out-of-network IHCP.
  • American Indian Plan members are not subject to enrollment fees, premiums, deductibles, copayments, cost sharing, or other similar charges. The Plan is prohibited from reducing payments due to a provider, including an IHCP, by the amount of any enrollment fee, premium, deductible, copayment, cost sharing or similar charge.

Tribal liaisons

The Plan is required to have a tribal liaison dedicated to working with each contracted and non-contracted IHCP in its service area. The tribal liaison is responsible for coordinating referrals and payment for services provided to American Indian Plan members.

The Plan’s tribal liaison serves in an active and engaged role in helping you with state requirements and policies. The tribal liaison can help you in ways that include, but are not limited to:

  • Providing information regarding enrollment and disenrollment of American Indian members;
  • Coordinating care with in- and out-of-network IHCPs for American Indian Plan members;
  • Ensuring access to care with in- and out-of-network IHCPs for American Indian Plan members;
  • Helping you and American Indian Plan members with accessing appropriate transportation given logistical and geographical barriers unique to tribal communities;
  • Providing case management for American Indian Plan members that involves in and out-of-network IHCPs;
  • Helping you with Provider Relations services, claims and payment assistance and resolution, and Member Services;
  • Providing support in obtaining grievance, appeal, and state hearing services in cases that impact American Indian Plan members;
  • Providing benefits and services navigation and coordination, such as those for Foster Care, Community-Based Adult Services, Enhanced Care Management, Community Supports, Behavioral Health, Health Education, Home and Community Based Services, California Children’s Services, etc., for IHCPs to provide full-spectrum services to American Indian Plan members;
  • Assisting internal Plan liaisons in instances that involve IHCPs and/or American Indian Plan members and the other liaisons’ respective services and program, in particular the Foster Care liaison, given the observed disproportionate representation of American Indian youth in the Foster Care system; as well as the liaisons for Long-Term Services and Supports, Transportation, California Children’s Services, Regional Center, Dental and In-Home Supportive Services; and
  • Helping you regarding Medi-Cal program provider enrollment and Plan contracting, credentialing and site reviews.

Additional information

Relevant sections of the provider operations manuals and Behavioral Health Provider Operations Manual have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on the provider portal.

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.

1Information throughout this communication was derived or taken from APL 24-002, Medi-Cal Managed Care Plan Responsibilities for Indian Health Care Providers and American Indian Members. https://www.dhcs.ca.gov/formsandpubs/Pages/AllPlanLetters.aspx.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Imperial county.



Last Updated: 05/01/2024