D3-CHSProcessHandout.pdf

Can CHS pay for your referral medical care? Find out in 3 stages.

Individual Qualifications

Stage 1

You are eligible if:

a) You are a member or descendent of a

Federally recognized Tribe or have close ties acknowledged by your Tribe*

b) You live on the reservation or, if you live outside the reservation, you live in a county of the CHSDA for your Tribe*

Each Contract Health Service Delivery Area

(CHSDA) covers a single Tribe or a few Tribes local to the area.* You are ineligible for CHS elsewhere.

and and

c) You get prior approval for each case of needed medical service or give notice within 72 hours in emergency cases (30 days for elders & disabled)

No for the above

Application is denied.

* There are a few narrowly defined exceptions. Ask

CHS staff for more specifics about individual eligibility, CHSDA, or prior notice.

Yes for all

Relative Medical Priorities

Stage 2

Payment may be approved if:

a) The health care service that you need is medically necessary

-- as indicated by medical documentation provided and

b) The service is not available at an accessible IHS or Tribal facility and and

d) CHS funds available are sufficient to pay for the service to be authorized

c) The facility’s CHS committee determines that your case is within the current medical priorities of the facility

Unfortunately, CHS funds often are not sufficient to pay for all needed services. When this happens, the committee considers each individual’s medical condition to rank cases in relative medical priority.

Cases with imminent threats to life, limb, or senses are ranked highest in priority. **

No for the above

Application is deferred.

** Ask CHS staff for more specifics. Sometimes deferred lower priority cases may be reconsidered later if funding permits.

Yes for all

Coordination and Payment

Stage 3

Approval, Billing, Payment

a) You must apply for any alternate resources for which you may be eligible

– Medicare, Medicaid, insurance, etc.

then

b) A CHS purchase order is issued to a provider authorizing payment for services then

c) IHS or Tribal staff and the authorized provider coordinate your medical care then

d) The authorized provider bills and collects from your alternate resources

e) The authorized provider bills any unpaid balance to CHS for payment -- because CHS is payer of last resort, it pays only for costs not paid by your alternate resources then

Steps are completed in order

Provider is paid.

Specific services authorized within relative medical priorities may vary from time-to-time in response to changing supply and demand, especially to stretch diminished funds over the remainder of the fiscal year.

Generally applicable Contract Health Services (CHS) rules and procedures are shown. Some nuances and exceptions are omitted. Talk to CHS staff if you have questions.