Indian Health Service (IHS)
- Indian Health Service (IHS)
- Billing Information
- Indian Health Service (IHS) Benefits
- UB-04 Paper Claim Reference Table
- Sterilizations, Hysterectomies and Abortions
- Timely Filing
- IHS Revisions Log
Indian Health Service (IHS)
Providers must be enrolled as a Health First Colorado (Colorado's Medicaid Program) provider in order to:
- Treat a Health First Colorado member
- Submit claims for payment to Health First Colorado
Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10 8.700), for specific information when providing FQHC and RHC services.
NOTE: Health First Colorado should be billed only in the event that an eligible American Indian Alaska Native (AIAN) member is enrolled in Health First Colorado. If the eligible member also possesses a third-party insurance plan, the private plan must be billed first. Any services not covered by the private insurance plan that are covered by Health First Colorado may then be billed. In the event an eligible AIAN member is dually eligible for Medicare and Health First Colorado, Medicare must be billed first. Any services not covered by Medicare that are covered by Health First Colorado may then be billed.
In order to bill as an IHS provider with Health First Colorado, the treatment facility must reside on land owned and operated by a federally recognized tribe as defined under Title IV of the Indian Health Care Improvement Act.
Urban Indian Organization (UIO)
Urban Indian Organizations (UIO) are currently ineligible to receive IHS designation under federal law. However, UIOs may apply to become a federally qualified health center (FQHC) with Health First Colorado, as long as they receive funds under Title V of the Indian Health Care Improvement Act.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
8.280.4.E Other EPSDT Benefits
Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:
- All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
- For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
- The service provides a safe environment or situation for the child.
- The service is not for the convenience of the caregiver.
- The service is medically necessary.
- The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
- The service is the least costly.
Refer to the General Provider Information Manual for general billing information.
Indian Health Service (IHS) Benefits
Payment for outpatient services rendered shall be paid per visit/encounter. Rates are determined by the U.S. Department of Health and Human Services and are published each year in the Federal Register. Please see the Federal Register IHS Encounter Rates table in the Coding section of this billing manual.
Health First Colorado covers the following outpatient services:
- Medical services
- Behavioral health services
- Hospital outpatient services
- Podiatry services
- Optometry services
- Radiology services
- Laboratory services
Health First Colorado shall reimburse multiple visit/encounter claims for a member on the same date of service by the same facility based on the following conditions:
- If the services provided are for different diagnoses and the claims each have a different diagnosis ICD-10 code, or
- If the services are in the categories of either medical, clinical laboratory, or radiology, based on the procedure code detail of the claim. If all three types of services are rendered then these three separate claims may be billed:
- Clinical Laboratory procedure codes. Code range 80047-89398
- Radiology procedure codes. Code range 70010-79999
- Medical services would be any other medical procedure code not in the Clinical Laboratory or Radiology category.
For separately reported services in multiple visit/encounter claims, bill with appropriate CPT codes for each service rendered.
Behavioral health services are a covered benefit. Behavioral health services must be billed using Revenue Code 900. Claims must be billed directly to Health First Colorado. These services are reimbursed the IHS outpatient encounter rate.
Health First Colorado covers inpatient services at IHS facilities. Payment for services rendered shall be per date of inpatient stay and is set in the Federal Register by the U.S. Department of Health and Human Services. Health First Colorado shall make only one payment per date of service per member. Please see the Federal Register IHS Encounter Rates table in the Coding section of this billing manual.
The Indian Self-Determination and Education Assistance Act, Pub. L. 93-638, gives Indian tribes the authority to contract with the government to operate programs serving their tribal members and other eligible persons. Tribal Federally Qualified Health Centers are facilities operated by a tribe or tribal organization for the provision of primary health services and are commonly referred to as Tribal 638 facilities. This section of the IHS Billing Manual only applies to the Tribal 638 facilities as specified in the Indian Self-Determination Act.
A tribal FQHC may bill Health First Colorado for covered services on a per-visit basis whether those services are furnished at the facility, outside the facility, or provided by off-site providers, whether tribal or non-tribal providers, under contract to the tribal FQHC. Tribal FQHCs are responsible for contracting the care for their tribal clients with the non-tribal provider.
Tribal facilities that are enrolled with Health First Colorado as a tribal FQHC that have agreed through tribal consultation to be paid for FQHC services using an Alternative Payment Methodology (AMP) will be paid the Indian Health Service all-inclusive rate (AIR) published annually in the Federal Register.
Urban Indian organization operated FQHCs are ineligible for this payment. Tribal FQHCs may bill the appropriate number of payable daily encounters based on the services that clients receive.
Professional services rendered by IHS providers at an inpatient hospital or ambulatory surgical center are billed on the professional claim type (837p/CMS1500) and are reimbursed at the Fee Schedule rate. Providers should refer to the billing manual for medical and surgical services found on the Billing Manuals web page under the CMS 1500 drop-down menu. Covered services include anesthesia services, obstetric services, medical services, vaccine/immunization services, psychiatric services, and surgical services as detailed in the medical and surgical services billing manual (see link above).
Pharmacy services rendered by an IHS pharmacy are covered by Health First Colorado, instructions can be found in the Pharmacy Billing Manual.
Dental services are covered by Health First Colorado, but must be billed to DentaQuest. For more information, see locator 42 on page 11 of this manual.
Urban Indian Organizations (UIO) that are designated as Federally Qualified Health Centers (FQHC) with Health First Colorado that use cost reports in lieu of the federal encounter rate should refer to the FQHC and Rural Health Care Billing Manual located on the Billing Manuals web page under the UB-04 drop-down menu.
IHS facilities are required to use revenue codes to bill Health First Colorado. The valid revenue codes for reimbursement are:
|Revenue Code||Type of Service|
|529||Physical Health (Outpatient)|
|900||Behavioral Health (Outpatient)|
|110||Inpatient Services (Physical and Behavioral Health)|
IHS services are priced at an encounter rate. All routine services are included in the encounter rate. Encounter rates for Tribal-FQHCs and IHS facilities are determined by the federal Department of Health and Human Services and are published in the Federal Register for each calendar year and are often referred to as the All-Inclusive Rate.
|Inpatient Hospital per Diem Rate (Excludes Physician/Practitioner Services)||$4,333|
|Outpatient per Visit Rate||$654|
In order to provide the Health First Colorado program with basic clinical information for use in evaluating services requested and received by Health First Colorado members, IHS and Tribal-FQHCs are required to include all procedure codes (CPT and HCPCS codes) for services provided during a visit on claims. To be reimbursed, a Tribal-FQHC or IHS facility that submits a UB-04 or 837 Institutional (837I) electronic transaction must have at least one (1) claim line that identifies revenue code 0529. All other lines on the claim should have the revenue code most appropriate for the service. The line item with revenue code 0529 or 0521 can appear at any line on the claim and with any procedure code.
UB-04 Paper Claim Reference Table
The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBCUB-04 Reference Manual.
All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.
The UB-04 Institutional Certification Form, located on the Provider Forms web page under the Claim Forms and Attachments drop-down menu, must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.
The Paper Claim Reference Table below lists the required, optional, or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for FQHC and RHC services.
|Form Locator and Labels||Completion Format||Instructions|
|1. Billing Provider Name, Address, Telephone Number||Text||Abbreviate the state using standard post office abbreviations. Enter the telephone number.
|2. Pay-to Name, Address, City, State||Text||Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
|3a. Patient Control Number||Up to 20 characters: Letters, numbers or hyphens||Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
|3b. Medical Record Number||17 digits||Optional
Enter the number assigned to the member to assist in retrieval of medical records.
|4. Type of Bill||3 digits||Required
IHS: Use type of Bill 71X or 77X for outpatient, 111 for inpatient.
|5. Federal Tax Number||None||Submitted information is not entered into the claim processing system.|
|6. Statement covers period From/Through||From:6 digits MMDDYY
Through: 6 digits MMDDYY
Each date of service must be billed on a separate line. Split an entire month into two claims. This FL must reflect the beginning and ending dates of service listed on the detail dates of service lines.
|8a. Patient Identifier||Submitted information is not entered into the claim processing system.|
|8b. Patient Name||Up to 25 characters, letters & spaces||Required
Enter the member's last name, first name and middle initial.
|9a. Patient Address - Street||Characters Letters & numbers||Required
Enter the member's street/post office box as determined at the time of admission.
|9b. Patient Address - City||Text||Required
Enter the member's city as determined at the time of admission
|9c. Patient Address - State||Text||Required
Enter the member's state as determined at the time of admission.
|9d. Patient Address - ZIP||Digits||Required
Enter the member's zip code as determined at the time of admission.
|9e. Patient Address - Country Code||Digits||Optional|
|10. Birthdate||8 digits (MMDDYYYY)||Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDYYYY format). Example: 01012010 for January 1, 2010.
|11. Patient Sex||1 letter||Required
Enter an M (male) or F (female) to indicate the member's sex.
|12. Admission Date||6 digits||Not Required|
|13. Admission Hour||6 digits||Not Required|
|14. Admission Type||1 digit||Conditional
Complete for emergency visits.
1 - Emergency
Member requires immediate intervention as a result of severe, life-threatening or potentially disabling conditions.
Exempts outpatient hospital claims from co-payment and PCP referral only if Revenue Code 0450 or 0459 is present. This is the only benefit service for an undocumented alien.
If span billing, emergency services cannot be included in the span bill and must be billed separately from other outpatient services.
|15. Source of Admission||1 digit||Not Required|
|16. Discharge Hour||2 digits||Not Required|
|17. Patient Discharge Status||2 digits||Not Required|
|18-28. Conditions Codes||2 digits||Conditional Complete with as many codes necessary to identify conditions related to this bill that may affect payer processing.
|29. Accident State||2 digits||Not required|
|31 - 34. Occurrence Code/Date||2 digits & 6 digits||Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
|35-36. Occurrence Span Code From/ Through||2 & 6 digits||Not required|
|38. Responsible Party Name/Address||None||Leave blank|
|39 - 41. Value Codes and Amounts||2 characters and up to 9 digits||Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
|42. Revenue Code||3 digits||Required
|43. Revenue code Description||Text||Required
Enter the revenue code description or abbreviated description.
When reporting an NDC:
|44. HCPCS/Rates/ HIPPS Rate Codes||5 digits||Required
Medical Claims - There may be multiple lines, each identified by revenue code 529 in locator 42. For each line enter a valid CPT code or HCPCS code that reflects the services rendered during the encounter. This includes any medical, laboratory, radiology, physical therapy, occupational therapy, pharmacy, supply or other service rendered during the encounter.
When a line identifies revenue code in the range of 0631-0636, the HCPCS will be required and an NDC.
CPT and HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.
On dental claims the D-code must be put in locator 44 on each line for dates of services prior to July 1, 2014. For dates of services after July 1, 2014, refer to the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest's website.
Behavioral Health Claims - There may be multiple lines, each identified by revenue code 900 in locator 42. For each line enter a short-term behavioral health service code that reflects the service rendered during the encounter.
HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.
|45. Service Date||6 digits||Required
Enter the date of service using MMDDYY format for each detail line completed.
Each date of service must fall within the date span entered in the "Statement Covers Period" (FL 6).
Not required for single date of service claims.
|46. Service Units||Up to 3 digits||Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)
|47. Total Charges||Up to 9 digits||Required
Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total in line 23 is required for all charges.
|48. Non-covered Charges||Up to 9 digits||Required
Enter incurred charges that are not payable by Health First Colorado.
Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges). Each column requires a grand total.
Non-covered charges cannot be billed for outpatient hospital laboratory or hospital-based transportation services.
|50. Payer Name||1 letter and text||Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
|51. Health Plan ID||8 digits||Required
Enter the provider's Health Plan ID for each payer name. Enter the eight-digit Health First Colorado
Program provider number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
|52. Release of Information||None|
|53. Assignment of Benefits||None|
|54. Prior Payments||Up to 9 digits||Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
|55. Estimated Amount Due||Up to 9 digits||Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
|56. National Provider Identifier (NPI)||10 digits||Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
|57. Other Provider ID||Submitted information is not entered into the claim processing system.|
|58. Insured's Name||Up to 30 characters||Required
Enter the member's name on the Health First Colorado line.
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
|60. Insured's Unique ID||Up to 20 characters||Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
|61. Insurance Group Name||14 letters||Conditional
Complete when there is third party coverage.
Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
|62. Insurance Group Number||17 digits||Conditional
Complete when there is third party coverage.
Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
|63. Treatment Authorization Code||Up to 18 characters||Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
|64. Document Control Number||Conditional|
|65. Employer Name||Text||Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
|66. Diagnosis Version Qualifier||Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
9ICD-10-CM (DOS 9/30/15 and before)
|67. Principal Diagnosis Code||Up to 6 digits||Required
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
Use diagnosis code
Z76.2 for EPSDT screenings.
|67A. - 67Q. - Other Diagnosis||6 digits||Optional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
|69. Admitting Diagnosis Code||6 digits||Not required|
|70. Patient Reason Diagnosis||Submitted information is not entered into the claim processing system.|
|71. PPS Code||Submitted information is not entered into the claim processing system.|
|72. External Cause of Injury code (E-Code)||6 digits||Required if known
Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
|74. Principal Procedure Code/Date||7 characters and 6 digits||Conditional
Enter the procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format.
Apply the following criteria to determine the principle procedure:
|74A. Other Procedure Code/Date||7 characters and 6 digits||Conditional
Complete when there are additional significant procedure codes.
Enter the procedure codes identifying all significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. Enter the date using MMDDYY format.
|76. Attending NPI - Required
Attending Last/First Name
|NPI - 10 digits
|Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in Health First Colorado.
QUAL - Enter "1D" for Medicaid
Enter the attending physician's last and first name.
This form locator must be completed for all services.
|77. Operating NPI||Submitted information is not entered into the claim processing system.|
|78 - 79. Other ID
NPI - Conditional
|NPI - 10 digits||Conditional
Complete when attending physician is not the PCP or to identify additional physicians.
NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.
The attending physician's last and first name are optional.
|80. Remarks||Text||Enter specific additional information necessary to process the claim or fulfill reporting requirements.|
|81. Code - QUAL/CODE/VALUE (a-d)||Qualifier: 2 digits
Taxonomy Code: 10 digits
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.
UB-04 Outpatient Claim Example
UB-04 Inpatient Claim Example
UB-04 Behavioral Health Claim Example
CMS 1500 Professional Claim Example
Sterilizations, Hysterectomies and Abortions
For information on this topic, refer to the Sterilization, Hysterectomies and Abortions section in the Obstetrical Care Billing Manual located on the Department's Billing Manuals web page under CMS 1500 > Obstetrical Care.
For more information on timely filing policy, including the resubmission rules for denied claims, refer to the General Provider Information Manual located on the Department's Billing Manuals web page.
IHS Revisions Log
|Revision Date||Changes||Made by|
|04/22/2019||Updated inpatient revenue code||Department|
|06/19/2019||Updated Appendices links and verbiage||DXC|
|10/02/2019||Updated Procedure Code/HCPCS||Department|
|12/02/2019||Converted to web page||Department|
|8/7/2020||Updated item 81 of the Paper Claim Reference Table for taxonomy code billing||DXC|
|10/7/2020||Changes made to Procedure Code Requirements||Department|
|2/1/2021||Updated the billing and coding portion to include multiple encounter policy for medical, lab, and radiology services.||Department|
|7/7/2021||Updating with the standard EPSDT policy language||HCPF|
|12/9/2022||Adding Tribal Federally Qualified Health Centers section to reflect the changes outlined in SPA CO 21-0001.||HCPF|
|1/26/2023||Adding clarifying billing information as well as the Federal Register IHS Encounter Rates table.||HCPF|
|3/8/2023||Updating the Federal Register IHS Encounter Rates table||HCPF|