OAR 410-146-0470: Traditional Health Care Practices

(1) Definitions: (a) Indian Health Care Provider (IHCP) means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1603). (b) Medicaid Management Information System (MMIS) means the automated claims processing and information retrieval system for handling all Medicaid transactions. The objectives of the system include verifying provider enrollment and client eligibility, managing health care provider claims and benefit package maintenance, and addressing a variety of Medicaid business needs (c) National Provider Identifier means a unique 10-digit number that is issued by the Centers for Medicare and Medicaid and is used to identify health care providers throughout the health care industry. (d) Prospective Payment System means the method of reimbursement in which payment is made based on a pre-determined, fixed amount. (e) IHCP Prospective Payment Rates (PPS) means payments made to an IHCP that is based on a clinic-specific, cost-based rate, calculated according to each IHCP’s reported costs and volume of patient encounters. (f) Tribal-Based Practices means those practices that are based on cultural principles that have been traditionally used in tribal communities since time immemorial. Tribal-Based Practices are culturally validated utilizing the process that has been established and been approved by the review panel of tribal representatives. Not all Tribal-based practices are eligible for Medicaid reimbursement. (g) Traditional Health Care Practices means those Tribal-based practices that have been determined to be eligible for Medicaid reimbursement. (h) Tribal Based Practices Review Panel means the panel comprised of tribal representatives who have been elected by representatives from the Nine Federally Recognized Tribes of Oregon. The Tribal Based Practices Review Panel is responsible for accepting, reviewing, and approving Tribal based practices that have been proposed and submitted to the Tribal Based Practices Review Panel for review and approval when evidence, based on research, practice, and culture-based knowledge, shows the Tribal-based practice to be effective. The Tribal Based Practices Review Panel may also provide technical assistance on an ongoing basis to the Tribes and Tribal Organizations regarding Tribal Based Practices. The panel meets on an as-needed basis. Review panel membership is determined by tribal representatives from the Nine Federally Recognized Tribes of Oregon. (i) Traditional Knowledge Keeper(s) means the individual(s) responsible for providing the Tribal Based Practices. Traditional Knowledge Keepers have gained the traditional knowledge according to their Tribal community that is necessary to implement Tribal Based Practices in a meaningful, respectful, and purposeful way. Examples of Traditional Knowledge Keepers may include elders, cultural or spiritual advisors, traditional foods providers, medicines gatherers, sweat lodge leaders, Tribal singers, dancers, artists, and more. These individuals must meet the qualifications in Section (5) of this rule and are authorized to provide Tribal Based Practices as an employee or contractor of an IHCP. (j) Urban Indian Health Program (UIHP) means an urban Indian organization as defined in section 1603 of Title 25 that has an IHS Title V contract as described in Section 1653 of Title 25. (2) Eligibility to Receive Tribal-Based Practices: To be eligible to receive one or more Tribal-Based Practice(s), an individual must meet the following criteria: (a) Is enrolled in Medicaid or CHIP; and, (b) Is able to receive services delivered by an Indian Health Care Provider (IHCP), as determined by the IHCP. (3) Delivery of Traditional Health Care Practices to Qualifying Individuals (a) The IHCP shall provide Traditional Health Care Practices to qualifying Medicaid or CHIP Members through employed or contracted Traditional Knowledge Keepers. (b) The Tribal Based Practices Review Panel shall review and maintain a list of available Tribal-Based Practices and the scope of each service. This list will identify the Tribal-Based Practices that are also approved as Traditional Health Care Practices and covered by Medicaid. (c) The IHCP shall determine the list and scope of each Traditional Health Care Practices that will be offered to qualifying Medicaid and CHIP Members at each IHCP. (d) Traditional Health Care Practices shall not be subject to OHP’s Prioritized List of Services as described in OAR 410-141-3830. (e) The IHCP shall maintain internal supporting documentation relating to the provision of the service for the OHP enrolled Member in accordance with OAR 410-120-1360. (4) Reimbursement for the Delivery of Tribal Based Practices (a) The IHCP shall be permitted to seek Medicaid reimbursement for expenditures on any Traditional Health Care Practice following the requirements outlined in this section. (b) The IHCP shall ensure that all Medicaid claims, even those claims that are for Traditional Health Care Practices provided to OHP Members enrolled in Coordinated Care Organizations (CCOs), are submitted to the Authority directly with the applicable information that identifies the IHCP as the Billing Provider, and the Traditional Knowledge Keeper identified as the Rendering Provider. The IHCP shall not submit Medicaid claims relating to the provision of Traditional Health Care Practices to CCOs. (c) The IHCP shall ensure that diagnosis code Z7689 and procedure code H0051 are used for the reimbursement of all Tribal-Based Practices claims. (d) The Authority shall process all Traditional Health Care Practices claims at the IHCP’s chosen specified encounter rate (Indian Health Service (IHS) or Prospective Payment System Rates (PPS)). (e) The Authority shall not provide Traditional Health Care Practice reimbursement for the following items or services: (A) Construction costs (including building modification and building rehabilitation); (B) Room and board; (C) Capital investments; and (D) Research grants and expenditures not related to monitoring and evaluation. (f) Payment for permissible claims submitted for the provision of Traditional Health Care Practices shall be contingent on the availability of federal funding. (5) Provider Qualifications for Traditional Knowledge Keepers (a) The IHCP shall be responsible for confirming that all contracted and employed Traditional Knowledge Keepers meet the qualifications described in this Section 5. (b) In order to receive OHP reimbursement for the provision of Traditional Health Care Practices, a Traditional Knowledge Keeper must be, at the time the practice was performed: (A) Be employed or contracted with an IHCP. (B) Meet Traditional Knowledge Keeper qualifications, as determined by the IHCP. (C) Have the necessary experience and appropriate training to serve as a Traditional Knowledge Keeper, as determined by the IHCP. (c) Each IHCP shall ensure the following for all the delivery of Tribal-Based Practices: (A) Establish methods for determining whether its employees or contractors are qualified to serve as Traditional Knowledge Keepers. (B) Bill the Authority for Traditional Health Care Practices furnished only by Traditional Knowledge Keepers who are qualified to provide them, as determined by the IHCP. (d) Each IHCP shall send the Authority a list of employed or contracted Traditional Knowledge Keepers, which must be updated as changes occur. Each IHCP must provide the Authority with copies of any updated list as they occur. (e) Each Traditional Knowledge Keeper on the list described in (5)(d) shall enroll with Oregon Health Plan (OHP) Open Card by submitting the necessary provider forms to OHA. (A) An IHCP shall not submit any claim for payment for the provision of any Traditional Health Care Practice by a Traditional Knowledge Keeper if such Traditional Knowledge Keeper was not enrolled with the Authority as required under this subsection at the time the practice was performed. (B) Traditional Knowledge Keepers shall not be required to have a National Provider Identifier (NPI) number. (f) The Authority shall verify that the Traditional Knowledge Keeper is on the list provided by each IHCP, as described in (5)(d) of this rule (g) Once verified, the Authority shall enroll the Traditional Knowledge Keeper in Medicaid Management Information System (MMIS).