D3_CHSProcessHandout.pdf
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- Attached to
- Non-Personal Healthcare Services-Physicians & Other Professional Ambulatory Services for PRC Program
- Solicitation number
- 75H70726R00002
About this file
This document is an informational guide outlining the eligibility and approval process for Contract Health Services (CHS) referral medical care provided by the Indian Health Service (IHS).
The CHS eligibility determination follows a three-stage process. Stage 1 establishes individual qualifications, requiring applicants to be members or descendants of a Federally recognized Tribe with close ties acknowledged by the Tribe, reside on or near the reservation within the applicable Contract Health Service Delivery Area (CHSDA), and obtain prior approval for medical services or provide notice within 72 hours for emergencies (30 days for elders and disabled individuals). Applicants failing to meet all Stage 1 criteria are denied. Stage 2 evaluates relative medical priorities for approved applicants, requiring that the needed health care service be medically necessary with documented medical evidence, unavailable at accessible IHS or Tribal facilities, deemed within the facility's current medical priorities by its CHS committee, and funded by available CHS appropriations. CHS funds are typically insufficient to cover all needed services, so the committee ranks cases by medical urgency, with imminent threats to life, limb, or senses receiving highest priority; applications not meeting Stage 2 requirements are deferred pending potential future reconsideration if funding becomes available. Stage 3 addresses coordination and payment, requiring applicants to apply for alternate resources such as Medicare, Medicaid, or insurance before CHS authorization, followed by CHS purchase order issuance, care coordination between IHS/Tribal staff and authorized providers, billing to alternate resources, and final CHS payment for any unpaid balances, as CHS functions as the payer of last resort.
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Text version
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.
File details come from the government source that posted it. Updated .