NWB Shoshone Community Health Department
This service delivery plan has been developed by the Community Health Department with technical assistance from the Indian Health Services. The purpose of this plan is to establish administrative responsibilities associated with the Contract Health Services Program.
The Contract Health Service program is not an entitlement program and thus when funds are insufficient to provide the volume of contract health services needed, priorities for services shall be determined on the basis of relative medical need.
Payor of Las Resort
The Tribal Contract Health Services, acting on behalf of the Indian Health Service, is the payor of last resort for eligible Tribal members under these regulations, notwithstanding any state or local law or regulation to the contrary. Accordingly, Tribal Contract Health Service will not be responsible for or authorize payment for Contract health Service to the extent that:
A The Tribal member is eligible for alternate resources or
The Tribal member would be eligible for alternative resources if he or she were to apply for them.
The payor of last resort rule does not represent a change in the Contract Health Services program requirements. These Contract Health Service office must first determine whether the patient applying for Contract heal Service funds is eligible. In addition, the Contract Health Service office must determine that the medical services requested for payment from Contract Health Service funds are within medical priorities.
To be eligible for contract health services, an individual must meet the eligibility requirements listed in the Indian Health Service manual as well as the requirements of 42 CFR 36.23. The individual must:
Be a member of the Northwestern Shoshone and have a permanent residence in the contract health service area (box Elder Count)
A non-Trivial member woman, pregnant with an eligible Tribal member’s child who resides within the contract health service area is eligible for contract health service during pregnancy through post partum (usually 6 weeks). If unmarried such a woman is eligible for contract health service id an eligible Trivial member states in writing that he is the father or the unborn child or such is determined by order of the court competent jurisdiction This will ensure health services to the unborn Indian Child.
A non-Tribal member of an eligible member’s household who resides within the contract health service area is eligible for contract health service if it is determined that services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.
Contract service delivery area.
Box Elder County, Utah
Notification and Authorization for Contract Health Services.
No payment will be made for medical care and services unless the requirements listed below have been met and a purchase order for care and services has been issued by the Tribe’s Contract Health Services Department.
Non-emergency cases- Eligible tribal members, eligible non-Tribal members, an individual or agency acting on behalf of the eligible person, or the medical care provider shall prior to providing medical care and services are requested services. They ust provide all of the necessary informant to determine the medical need for the services and the individual’s eligibility.
Eligible individuals who are referred by a physician to other medical care providers (physicians, laboratory, radiology, physical therapy, etc.) must notify contract health services and receive authorization.
Emergency cases- Eligible Tribal member, eligible non-Tribal member an individual or agency acting on behalf of the eligible person, or the medical care provider shall, within 72 hours after the beginning of treatment or after admission to a health care facility notify the Contract Health Service Department of the admission or treatment and provide information to determine the relative medical need for the service.
The cost of medical care at an emergency facility is three of four time greater than cost of medical care at non-emergency facilities. Therefore, authorization for service of non emergent / acutely urgent care at an emergency facility will be denied.
Notification Requirements - The above notification requirements apply to all categories of eligible individuals which includes students, transients, persons who leave the service area and resident who live in the service area.
Authorization Denial - Eligible individual whose request for contract health services was denied due to the level of service requested and funding will be placed on a deferred services list. These individual will be granted authorization as funds become available on a first come first serve basis.
Denials and Appeals
If a person is denied contract health services or if the medical provider may reasonably think Indian Health Service will be a party to payment, both the patient and the provider shall be notified in writing of the denial with a statement containing all the reasons for the denial. The notice shall also inform the applicant that within thirty (30) days from the receipt of the notice the applicant:
May request a reconsideration by the Health Administrator of the Tribe. A request for reconsideration must contain additional information not previously submitted, or
May appeal the original denial by the Assistant Operations manager to the Area Director, Indian Health Services, if there is no additional information on which to base reconsideration.
Appeals may be submitted by providers. The provider will be considered as acting on behalf of the patient. A response will be provided to the provider and a courtesy copy may be sent to the patient.
In the event the Area Director, Indian Health service, upholds the Assistant Operations Manger’s denial, the applicant must be notified in writing of the denial, and that an appeal may be submitted in writing to the Director, Indian Health services, within thirty (30) days.
If that claimant fails to follow procedures, the request for reconsideration of an appeal may be devised. A written notice of denial will be sent to the claimant.
The contract Health Service regulations currently in effect only allows three (3) levels of appeal. The three levels are: request for reconsideration of the Health Administrators denial; appeal to the Area Director; and final administrative appeal to the Director, Indian Health Services.
Payments and Reconciliation of Commitment Registers
Payment of the Contract Health Services purchase orders are required in a timely manner. The contract health service department will issue checks weekly.
The Tribe is required under the terms of the contact to submit data to the Indian Health Service for statistical purposes. This data is requested twice a moth and is often referred to as UNICOR data. Each Tuesday morning of the week the Portland Area Office requests that all tribes call in what is referred to as a weekly status report. That is the total weekly obligations, and the last document that was issued. This will assist the Area Office by monitoring funding levels.
Tribal Contract Health Service Department telephone number 735-734-2286. Individuals eligible for Contract Health Service are encouraged to contact Robin at the Contract Health Service Department should they have any questions.