mmpc - National Indian Health Board

Under federal law, There are privacy rules governing quality assurance for the I/T/U that must
be considered as requirements are imposed by the QHP. IHCIA §805 (25 U.S.C. §1675)
facilitates internal medical program quality reviews; shields participants in those reviews; and
restricts disclosure of medical quality assurance records. This provision applies to the IHS,
Indian tribes, tribal organizations and urban Indian organizations.
14. Claims Format.
An I/T/U may use a claims format offered by the QHP, or it may submit claims in a format that
is consistent with Medicare claims. IHCIA §206(h) (25 U.S.C. §1621e(h) prohibits insurance
carriers from denying a claim submitted by IHS, an Indian tribe or tribal organization based on
the format on which the claim is submitted if the format complies with the Medicare claims
format requirements.
15. Payment Rate.
IHCIA §206(a) and (i) (25 U.S.C. §1621e(a) and (i)) provides that the IHS, an Indian tribe, tribal
organization and urban Indian organization have the right to recover the reasonable charges
billed, or, if higher, the highest amount an insurance carrier would pay to other providers. This
Addendum provision states that a QHP must pay claims to the I/T/U according to IHCIA Section
206 except to the extent the Indian Health Care Provider expressly agrees in writing to accept rates or
amounts specified in [specify payment schedule here] as payment in full, except that such rates or
amounts may not be lower than the Qualified Health Plan pays to any of its other preferred or in-network
providers .
16. Hours and Days of Service.
QHP may not require the I/T/U to provide services at times they would not otherwise provide
services for the IHS beneficiaries. For example, some I/T/U clinics are open only a few days a
week and some do not provide 24-call.
17. Sovereign Immunity.
Becasuse tribes are soverign governments, This provision provides that nothing in the agreement
shall constitute a waiver of federal or tribal sovereign immunity from suit.
18. Endorsement.
IHS providers and employees are prohibited from officially endorsing any non-federal entity.
This provision ensures that no such endorsement is implied by signing the agreement.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 6
Comment [A4]: State the basis. Can we hook to
some federal provision?