Tribal Health Program Tool-Kit Updated 1/26/2016 CRIHB Options 2015 California Rural Indian Health Board, Inc. 4400 Auburn Blvd., 2nd Fl. Sacramento, CA 95841 (916) 929-9761
[email protected] www.crihb.org 1 Table of Contents Page # High-Level Screening and Eligibility 4-31 . Client High-Level Screening and Eligibility Form……………………………………........... 5 . Benefit ID Number Instructions………………………………………………………………………. 6 . IHS Eligible Criteria…………………………………………………………………………………………. 7 . Tribal Affiliation Codes……………………………………………………………………………………. 9-29 . Frequently Asked Questions (FAQs)………………………………………………………………… 30-31 Service Codes 32-44 . Acupuncture Services……………………………………………………………………………………… 33 . Audiology Services………………………………………………………………………………………….. 34 . Chiropractic Services………………………………………………………………………………………. 35 . Dental Services……………………………………………………………………………………………….. 36-40 . Podiatry Services…………………………………………………………………………………………….. 41-43 . Speech Therapy Services…………………………………………………………………………………. 44 Submitting Claims to CRIHB Options 45-63 . Claims processing and payments via Humboldt Independent Practice Association……………………………………………………………………………………………………. 46-50 . Claims submission via clearinghouse: Office Ally……………………………………………. 51-57 . Check claim status via Humboldt Independent Practice Association……………... 58-61 . Sample UB-04 Claim Form: Medical……………………………………………………………….. 62 . Sample UB-04 Claim Form: Dental………………………………………………………………….. 63 CRIHB Options Policies 64-88 . 101 — Program Description…………………………………………………………………………… 65-66 . 102 — Eligibility for