Part 2 - Services To Indians And Others
Chapter 3 - Contract Health Services
- Purpose. This revised chapter consolidates the policy, procedures, and guidance for the effective management of the Indian Health Service (IHS) Contract Health Services (CHS) Program. The authority to manage the operation of the CHS Program is delegated to the greatest degree possible, within the limits of available funds to Area Directors and Chief Executive Officers (CEO).
- “Geographic Composition of the Contract Health Service Delivery Areas (CHSDA) and Service Delivery Areas (SDA) of the Indian Health Service,” Federal Register (FR): June 21, 2007 (Volume 72, Number 119) Pages 34262-34267
- “Persons to whom services will be provided.” 42 Code of Federal Regulations (CFR), Title 42, §136.12
- “Definitions.” 42 CFR §136.21
- “Establishment of contract health service delivery areas.” 42 CFR §136.22
- “Redesignation of contract health service delivery areas.” 42 CFR §136.22(b)
- “Persons to whom contract health services will be provided.” 42 CFR §136.23
- “Priorities for contract health services.” 42 CFR §136.23(e)
- “Payor of last resort.” 42 CFR §136.61
- “Administrative Procedures Act,” 5 United States Code (U.S.C.) 500, et seq.
- “Alaska Native Claims Settlement Act,” 43 U.S.C., 1601 et seq.
- “The Victims of Crime Act of 1984” 42 U.S.C. 112, §10601
- “Indian Civil Rights Act of 1968,” 25 U.S.C. 1301, et seq.
- “Eligibility of California Indians,” Rancheria Act of August 18, 1958, (72 Statutes at Large (STAT.) 619)
- “Social Security Amendments of 1972,” Public Law (P.L.) 92-603
- “Indian Self-Determination and Education Assistance Act,” P.L. 93-638, as amended
- “Indian Health Care Improvement Act,” P.L. 94-437, as amended
- “Electronic Signatures in Global and National Commerce Act,” P.L. 106-229
- “Federal Managers’ Financial Integrity Act of 1982,” P.L. 97-255
- “The Fiscal Year (FY) 1987 Appropriations Act for the IHS,” P.L. 99-591
- “Consolidated Omnibus Budget Reconciliation Act of 1985,” P.L. 99-272, Section 17003
- Policy. It is IHS policy to ensure that CHS funds are used to supplement and complement other health care resources available to eligible American Indian and Alaska Native (AI/AN) people. Contract Health Service funds are utilized in situations, where:
- no IHS direct care facility exists;
- the existing IHS direct care element is incapable of providing required emergency and/or specialty care;
- utilization in the direct care element exceeds existing staffing; and
- supplementation of alternate resources (i.e., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible AI/ANs.
- CEO - Chief Executive Officer
- CFR - Code of Federal Regulations
- CHEF - Catastrophic Health Emergency Fund
- CHS - Contract Health Services
- CHSDA - Contract Health Service Delivery Area
- CHS/MIS - Contract Health Services/Management Information System
- CHSO - Contract Health Service Officer
- CDSR - Core Data Set Requirement
- DCC - Division of Contract Care
- FMCRA - Federal Medical Care Recovery Act
- FMFIA - Federal Managers' Financial Integrity Act
- FI - Fiscal Intermediary
- FR - Federal Register
- HIPAA - Health Insurance Portability and Accountability Act
- IHCIA - Indian Health Care Improvement Act
- RPMS - Resource and Patient Management System
- UFMS - Unified Financial Management System
- U.S.C. - United States Code
- Definitions. (See also 42 CFR §136.21)
- Alternate Resources. Health care resources other than those of the IHS. Such resources include health care providers, institutions, or health care programs for the payment of health services including, but not limited to programs under Titles XVIII and XIX of the Social Security Act (i.e., Medicare and Medicaid, State Children’s Health Insurance Program), State and local health care programs and private insurance.
- Appropriate Ordering Official. The person with documented procurement authority who signs purchase orders authorizing the obligation of CHS funds.
- Area Director. The Director of an IHS Area Office designated for purposes of administration of IHS programs.
- Catastrophic Health Emergency Fund. The fund appropriated by Congress to partially cover the IHS portion of medical expenses for catastrophic illnesses and events that are covered by IHS CHS medical priorities. The IHS will pay, from the CHEF, for cases that are covered by IHS CHS medical priorities. The IHS is not responsible to cover cases that are expensive but outside the CHS medical priorities.
- Chief Executive Officer. The CEO holds the overall responsibility for and the administration of health service program activities occurring at the Service Unit level. Program activities are categorized as administrative, clinical, or financial in nature.
- Contract Health Service Delivery Area. The geographic areas within which CHS will be made available by the IHS.
- Contract Health Services. Health services paid by the IHS that are provided to eligible AI/ANs by non-IHS public or private providers (e.g., dentists, physicians, hospitals).
- Contract Health Services Eligible Person. A person as defined in Section 2-3.6 of this chapter as being eligible for CHS.
- Contract Health Services to Support Direct Care. These are medical services provided in an IHS facility when the patient is under direct supervision of an IHS physician or a contract physician practicing under the auspices (or authority) of an IHS facility.
- Contract Health Services Core Data Set. The CHS Core Data Set consists of data required for management of the CHS program that constitutes a subset of data collected in the IHS information system. The purpose of the data is to assist the IHS in its internal management and to satisfy congressional and other mandatory reporting requirements.
- Emergency. Any medical condition for which immediate medical attention is necessary to prevent the death or serious impairment of an individual’s health.
- E-SIGN. The electronic equivalent of a hand-written signature requiring user authentication and verification, such as a digital certificate, smart card, or biometric methods. On June 30, 2000, Congress enacted the “Electronic Signatures in Global and National Commerce Act,” (E-SIGN) to expand the use of electronic records and signatures in interstate and foreign commerce and ensure the validity and legal effect of contracts entered into electronically. E-SIGN ensures that contracts and purchase orders entered into electronically will be legally effective and valid, and that consumers who enter into contracts electronically have the same protections they have when contracting in the “brick and mortar” world.
- Fiscal Intermediary. The fiscal agent is an organization contracted by the IHS to validate and pay CHS claims.
- Indian Tribe. Any Indian Tribe, band, nation, group, Pueblo or community, including any Alaska Native village or Native group, which is Federally-recognized as eligible for the special programs and services provided by the United States (U.S.) to AI/ANs, because of this status.
- Reservation. Any Federally Recognized Indian Tribe’s reservation, Pueblo, colony, or Rancheria, including former reservations in Oklahoma, and Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. 1601, et seq.) and Indian allotments.
- Residence. Where a person lives and makes his or her home as evidenced by acceptable proof of residency or acceptable proof established by the Service Unit.
- Secretary. The Secretary of the Department of Health and Human Services (HHS).
- Service. The Indian Health Service.
- Tribal Health Director. The Director of a tribally-operated program, or his/her designee, authorized to make decisions on payment of CHS funds pursuant to a P.L. 93-638 contract.
- Tribal Member. A person who is an enrolled descendent of a Federally Recognized Tribe or is granted Tribal membership by some other criteria in the Tribal constitution.
- Tribally-Operated Program. A program operated by a Tribe or Tribal organization that has contracted under P.L. 93-638 to provide a CHS program.
- Tribal Self-Insurance. A health plan that is funded solely by a Tribe or Tribal organization and for which the Tribe or Tribal organization assumes payment for health services covered under the plan either directly or through an administrator. The plan may be re-insured, but the Tribe or Tribal organization must bear some risk.
- Director, Division of Contract Care. The Director, Division of Contract Care (DCC) will:
- Establish general policies regarding the administration of the CHS program in the IHS.
- Establish standards of performance for Area, Service Unit, and FI operations of CHS.
- Assess the performance of the CHS program at the Area and Service Unit levels; and the FI against established standards.
- Assess the long-term purpose and direction of the CHS program to ensure maximum effectiveness of the program in meeting the health needs of Indian people.
- Formulate long-term plans and objectives for the future development of the CHS program.
- Provide staff assistance to Area Offices in matters of general policies and procedures.
- Prepare budget justification for the total CHS program.
- Allocate funds through the Office of Finance and Accounting to Area Directors.
- Promptly and appropriately respond to CHS appeal denials by IHS Area Offices.
- Provide guidance in the establishment of Area medical priorities.
- Provide project officer services for the FI contract and all FI evaluation projects.
- Respond to congressional questions and requests for information from the CHS program.
- Centrally manage the CHEF.
- Establish general guidelines and policies for applying managed care practices and CHS quality assurance activities in the Areas and Service Units.
- Establish and implement a management control system for the CHS function that conforms to the requirements of the “Federal Managers’ Financial Integrity Act (FMFIA),” Section 2 (31 U.S.C. 3512 (b)), and IHS policies and procedures cited in Part 5, Chapter 16, “Management Control Systems,” Indian Health Manual (IHM).
- Area Director. The Area Director administers the Area Office CHS program, ensuring that the program operates within regulations, policies, procedures, and the budget. The Area Director will:
- Develop and establish policies and methods for the direction, control, review, and evaluation of the Area and Service Unit CHS programs.
- Establish Area medical priorities for the care of eligible AI/AN people that will most effectively meet their needs within the funds available that are consistent with the national IHS medical priorities.
- Maintain records for planning and for controlling funds and furnish reports to IHS Headquarters as required.
- Allocate an equitable share of funds among the CHS Service Units based on established formulas agreed to by the Tribes.
- Establish Contracts/Rates Quote Agreements in coordination with CEOs for needed services with hospitals, clinics, physicians, dentists, and others in accordance with the Area policies and established regulations, the CHS payment policy of June 30, 1986, and policy and procedures established in the Part 5, Chapter 5, Section 13, “Acquisition of Health Care Services,” IHM.
- Coordinate appropriate contract activities with the Contracting Officer.
- Periodically review and evaluate the quality and effectiveness of services provided under contract. In carrying out this responsibility, Areas are encouraged to utilize the services of one or more Quality Improvement Organizations (QIO) originally known as Peer Review Organizations (PRO). The name was officially changed to QIO via regulations published in the May 24, 2002 FR.
- Promptly and appropriately respond to CHS appeal denials by Service Units.
- Act promptly and appropriately on appeals from P.L. 93-638 operated CHS programs if the program has elected to follow the IHS appeals process.
- Monitor the CHEF cases submitted by the Service Units or P.L. 93-638 operated CHS programs.
- Establish general guidelines and policies for applying managed care practices and CHS quality assurance activities in the Areas or Service Units.
- Be responsible for the internal controls related to the FMFIA.
2-3.3 CONTRACT HEALTH SERVICE DELIVERY AREA
- Contract Health Service Delivery Area. All approved Contract Health Service Delivery Areas (CHSDA) are specified in 42 CFR §136.22 and may be changed only in accordance with the Administrative Procedures Act (5 U.S.C. 553).
- Established Contract Health Service Delivery Areas. Established CHSDA are identified below:
- The State of Alaska.
- The State of Nevada.
- The State of Oklahoma.
- Chippewa, Mackinac, Luce, Alger, Schoolcraft, Delta, and Marquette counties in the State of Michigan.
- Clark, Eau Claire, Jackson, Lacrosse, Monroe, Vernon, Crawford, Shawano, Marathon, Wood, Juneau, Adams, Columbia, and Sauk counties in the State of Wisconsin, and Houston County in the State of Minnesota.
- The State of California, excluding the counties of Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, San Mateo, Kern, Merced, Monterey, Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura.
- Aberdeen Area -Trenton (Turtle Mountain Chippewa), North Dakota.
- Aberdeen Area - Northern Ponca, Nebraska.
- With respect to all other reservations, within the funded scope of the Indian health program, the CHSDA consists of a county that includes all or part of a reservation, and any county or counties that have a common boundary with the reservation.
- In addition, Congress statutorily creates or re-designates the CHSDA through legislative enactments such as appropriations, restoration and/or recognition acts, public laws, etc. This information is dissemenated to the public through Federal Register (FR) Notices, as necessary.
2-3.4 REDESIGNATION OF A CHSDA
- Re-designation Request. The Tribal group(s) affected, or the IHS, (after consultation with the affected Tribal group(s)) may request re-designation of a CHSDA. All requests for re-designation shall contain the following information:
- The estimated number of AI/AN people who will be included and/or excluded regarding CHS eligibility.
- The Tribal governing body's designation of categories of AI/AN people to be included and/or excluded from CHS eligibility, e.g.,
- members of the Tribe who live near the reservation or
- American Indian/Alaska Native people, who are not members of the Tribe, but have close economic and social ties with the Tribe.
- Re-designation Request Requirements.
- The re-designation of a CHSDA may not result in the exclusion of Indian people eligible under 42 CFR §136.23(a)(1), i.e., reservation residents.
- The estimated costs of including additional AI/AN people in the CHSDA are determined according to the IHS resource allocation guidelines currently in effect.
- The effect of changing the CHSDA on the level of CHS funding being provided to eligible AI/AN in the originally configured CHSDA.
- The justification for the CHSDA change may include, but is not limited to, criteria used in establishing the CHSDA for the States of Oklahoma, Nevada, Michigan, and Minnesota as outlined in 42 CFR §136.22.
- Submission of a Request for Proposed CHSDA Change. All proposed CHSDA changes must be submitted to the Area Office of the affected Tribe for review and forwarding to IHS Headquarters for appropriate action.
- The Area CHS Officer will analyze the proposal outlining positive and negative features, and will recommend acceptance or rejection of the request to the Area Director. For tribally-managed programs, the analysis will be coordinated with the Area Tribal Project Officer for contracted programs or the Self-Governance Coordinator for compacted programs.
- The Area Director then forwards the recommendation, in writing to the Director, DCC, for appropriate action.
- The Director, DCC, reviews the recommendation for the re-designation of the CHSDA, and applies the criteria outlined in Paragraph A and B in this section to the information submitted to support the recommendation.
- After review, the Director, DCC, shall prepare a report finding as to whether the criterion have been met. The Director, DCC, will submit his/her written recommendation via memorandum, as to whether the request for the re-designation should be granted, to the Director, IHS.
- Tribal Consultation. The regulations at 42 CFR §136.22(b) state that after consultation with the Tribal governing body or bodies of those reservations included in the CHSDA, the Secretary may from time to time, re-designate areas within the United States for inclusion in or exclusion from a CHSDA. Consultation with the affected Tribe(s) occurs during the review of the request for re-designation, and the IHS publishes a notice in the Federal Register (FR) requesting public comments as part of the consultation process. (See Manual Exhibit 2-3-M for sample materials on re-designation of a CHSDA.)
- After determining that a re-designation of a Tribe’s CHSDA should be made, the IHS shall publish a notice with comment period in the FR advising the public that the IHS proposes to re-designate a particular Tribe’s CHSDA.
- The FR notice with request for public comments shall include:
- The proposed action and the background information sufficient to provide the public an explanation for the Agency's decision.
- A statement as to the date when comments must be received. There must be at least a 30-day "comment" period from the date of the notice's publication.
- Reference to the legal authority and the name and address of the public official to whom comments should be addressed.
- Effective Date of CHSDA Change. After determining that a Tribe’s CHSDA should still be re-designated, IHS publication of the public notice with a comment period, and review of any comments received, the IHS shall publish a final notice advising the public of the decision. Any change to the CHSDA is effective on the date of publication of the final notice in the FR.
- Additional Counties. Counties may be added to a Tribe’s CHSDA by operation of the CHS regulations when:
- the IHS inadvertently or mistakenly omits the county from the Tribe’s CHSDA list or
- the Tribe’s reservation was expanded or created by a proclamation issued by the Secretary of Interior or by congressional statute, e.g., Federal recognition of a Tribe.
- Exception. Under exceptional circumstances, the public notice and comment process described in paragraphs 2-3.4A-F is not necessary. Instead, a memorandum from the Director, IHS, is mailed to the respective Area Director regarding the action resulting in the creation, correction, or expansion of the Tribe’s CHSDA, with instructions to the Area Director to contact the Tribe with this information.
2-3.5 PERSONS TO WHOM CHS WILL BE PROVIDED
- Authority. The CFR, Title 42 Part 136 is the appropriate citation for all correspondence to providers and AI/AN patients. This IHM chapter should not be cited as the authority for making decisions on eligibility or payment denials.
- Funds Available. There is no authority to authorize payment for services under the CHS program unless funds are available.
- Any expenditure of CHS funds is limited to medically indicated services. See Manual Exhibit 2-3-D “Contract Health Services Medical Priorities” for services that may be included and those specifically excluded.
- No CHS funds may be expended for services that are reasonably accessible and available at IHS facilities.
- The determination of whether an IHS or tribally-operated facility is “reasonably accessible and available” is made by the CEO, based on the following criteria:
- Determination by a qualified IHS Clinical health professional of the patient’s medical condition at admission, i.e., emergent, urgent, or routine.
- The capacity of the IHS or Tribal facility to provide the necessary service.
- The level of funding available to provide CHS.
- Distance from the IHS or Tribal facility.
- Guidelines. The following guidelines will be used in applying the above criteria:
- There must be a compelling reason to believe, upon review of the medical record and assessment of the patient's situation, that without immediate medical treatment an individual’s life or limb would have been endangered.
- Available CHS funds may be authorized for an emergency to the extent that the contract facility is the nearest available provider capable of providing the necessary services and the patient’s condition dictates that he/she be transported to that facility.
- Medical and dental priorities (Manual Exhibits 2-3-D and E) include a list of diagnostic categories that have been administratively determined to be emergencies. This list is not all inclusive and other conditions may be included as an emergency when so determined by a qualified IHS clinical health professional.
- The final decision as to classification of medical services as “emergency” will be based on review by a qualified IHS clinical health professional or by documented medical history.
- Services for an acute condition (urgent but not emergent) may be provided through CHS funds when the nature of the medical need of the patient, as determined by a qualified IHS clinical health professional, can best be met by using a contract facility and when sufficient CHS funds are available for this level of service.
- Routine health services (not urgent or emergent) should ordinarily be provided by IHS or Tribal staff and facilities.
- Routine health services may be provided through the CHS Program when the CEO has determined that sufficient CHS funds are available for this priority of medical service. As a general rule, routine health services will not be provided through CHS when an IHS or Tribal facility capable of providing these services is within 90 minutes one-way surface transportation time from the patient’s place of residence.
- Each Service Unit may develop policy or policies, with Tribal participation, on the availability and accessibility of IHS facilities if the criteria to be used are different than the previous guidance specified in this section. Contract Health Service policies will be posted in a publicly accessible location and published to maximize knowledge among the AI/AN population served.
- Contract Health Service funds may be expended for services to support individuals receiving direct care in an IHS or Tribal facility to the extent that the individual is eligible for direct services. However, hospital and clinic funds shall be used to support direct care whenever possible. Payment for services contracted to support direct care (e.g., prenatal, podiatry, or orthopedic care) provided within the facility are permitted when patients are under the direct supervision of an IHS or Tribal physician or a contract physician practicing under the auspices of IHS or Tribal facility medical staff rules or regulations. Most services in a non-IHS or non-tribally operated facility are not included unless the patient meets CHS eligibility criteria of Title 42 CFR §136.23, “Persons to whom Contract Health Services will be provided.”
2-3.6 CONTRACT HEALTH SERVICE ELIGIBILITY REQUIREMENTS
- Documentation. An AI/AN claiming eligibility for CHS has the responsibility to furnish the CEO or the Tribal program with documentation to substantiate the claim.
- Eligibility. The definition of eligibility for CHS shall be consistent with Title 42 CFR § 136.23. If local rules and Title 42 CFR §136.23 conflict, Federal regulations prevail. To be eligible for CHS an individual must:
- Be eligible for direct care as defined in 42 CFR §136.12;
- Reside within the U.S. on a Federally-Recognized Indian reservation; or
- Reside within a CHSDA and;
- Be a member of the Tribe or Tribes located on that reservation; or
- Maintain close economic and social ties with that Tribe or Tribes.
- Close Economic and Social Ties. The basis for determining a person’s close economic and social ties is established by the Tribe(s) served and may include the following:
- The person is employed by a Tribe whose reservation is located within a CHSDA in which the person lives;
- The person is married to or is the child of (see 2-3.6K (2) below), an eligible member of the Tribe; or
- The Tribe where the person resides determines and certifies that the person has close economic and social ties with the Tribe whose reservation is located within the CHSDA.
- Full-time Student. Contract Health Services will be made available to the following students who would be eligible at the place of their permanent residence, but who are temporarily absent from their residence:
- Full-time students in college (undergraduate and graduate) vocational, technical, or other academic institutions, during their attendance and established school breaks. The Service Unit where the student was eligible for CHS prior to leaving for school is responsible for the student. The student remains eligible for CHS 180 days after completing courses of study.
- Full-time Bureau of Indian Affairs (BIA) boarding school students can receive CHS whether or not they resided in a CHSDA before attending the school. Contract Health Services are provided for them during their full-time attendance, by the Area in which the boarding school is located. Included are BIA off-reservation schools such as Flandreau Indian School, Moody County, South Dakota; Wahpeton Indian School, Richland County, North Dakota; Sherman Indian High School, Riverside County, California; Riverside Indian School, Caddo County, Oklahoma; and Chemawa Indian School, Marion County, Oregon.
- While the students are on a scheduled break or vacation, their permanent area of residence is responsible for payment of CHS services.
- Transients. Persons who are traveling or who are temporarily employed, such as seasonal or migratory workers, are eligible for CHS at their permanent residence.
- Other Persons Outside the CHSDA. Persons who leave the CHSDA in which they are eligible for CHS and who are neither students nor transients will be eligible for CHS for a period not to exceed 180 days from such departure.
- Other Eligibility Considerations. To be eligible for CHS, an Indian is not required to be a citizen of the U.S. However, the Indian (e.g., a citizen of Canada or Mexico) must reside in the U.S. and be a member of a Tribe whose traditional land is divided by the Canadian border (e.g., St. Regis Mohawk, Blackfeet) or Mexican border (e.g., Tohono O’Odham).
- California Indians. Section 809(b) of the Indian Health Care Improvement Act, (IHCIA) P.L. 94-437, states that the following California Indians shall be eligible for CHS:
- Any member of a Federally-recognized Indian Tribe;
- Any descendent of an Indian who was residing in California on June 1, 1852, but only if such descendent:
- is living in California,
- is a member if the Indian community served by a local program of the Service, and
- is regarded as an Indian by the community in which the descendent lives; or any Indian who holds trust interests in public domain, national forest, or Indian reservation allotments in California; and any Indian in California who is listed on the plans for distribution of assets of California Rancherias and reservations under the Rancheria Act of August 18, 1958 (72 STAT. 619), and any descendent of such an Indian.
- Section 809(c) of the IHCIA states that nothing in this Section may be construed as expanding the eligibility of California Indians for health services provided by the Service beyond the scope of eligibility for such health services that applied on May 1, 1986.
- American Indian/Alaska Native Children Adopted by Non-Indian Parents. Indians adopted by non-Indian parents must meet all CHS requirements to be eligible for care (e.g., reside within a CHSDA).
- Foster Children. American Indian/Alaska Native children who are placed in foster care outside a CHSDA by order of a court of competent jurisdiction and who were eligible for CHS at the time of the court order shall continue to be eligible for CHS while in foster care. Section 813(a)(1) of the IHCIA, states in part: “Any individual who-(A) has not attained 19 years of age, (B) is the natural or adopted child, step-child, foster-child, legal ward, or orphan of an eligible Indian, and (C) is not otherwise eligible for the health services provided by the Service, shall be eligible for all health services provided by the Service on the same basis and subject to the same rules that apply to eligible Indians until such individual attains 19 years of age.”
- Non-Indian Pregnant Woman. A non-American Indian/Alaska Native woman pregnant with an eligible AI/AN’s child who resides within a CHSDA is eligible for CHS during pregnancy through post-partum (usually 6 weeks). If unmarried, the non-AI/AN pregnant woman is eligible for CHS if the eligible AI/AN male states in writing that he is the father of the unborn child or if such a court of competent jurisdiction determines the eligible AI/AN male is the father. This will ensure health services to the unborn AI/AN child. Section 813(a)(2) of the IHCIA states in part: “Any spouse of an eligible Indian who is not an Indian, or who is of Indian descent but not otherwise eligible for the health services provided by the service, shall be eligible for such health services if all of such spouses are made eligible, as a class, by an appropriate resolution of the governing body of the Indian Tribe of the eligible Indian.”
- Non-Indian. A non-Indian member of an eligible AI/AN’s household who resides within a CHSDA is eligible for CHS if the medical officer in charge determines that services are necessary to control a public health hazard such as an acute infectious disease.
Federal regulations permit the establishment of priorities based on relative medical need when funds are insufficient to provide the volume of CHS indicated as needed by the population residing in a CHSDA. The list of IHS medical priorities is found in Manual Exhibit 2-3-D. (Tribal programs that elect to follow IHS regulations may use Manual Exhibit 2-3-D priorities as guidelines.)
Area-wide priorities are established to ensure an equivalent level of services in all Service Units, taking into consideration the availability and accessibility of IHS or Tribal facilities, the population being served, the relative cost of services, and the availability of alternate resources. Priorities established to limit services, whether on an Area-wide or Service Unit basis, shall be made known to the AI/AN population being served through publication in local community and/or Tribal newspapers and posting of notices on bulletin boards in patient waiting areas of IHS or Tribal facilities.
2-3.8 PAYOR OF LAST RESORT REQUIREMENTS
- Payor of Last Resort Title 42 CFR §136.61. The IHS is the payor of last resort for services provided to patients defined as eligible for CHS under these regulations, notwithstanding any State or local law or regulation to the contrary. Accordingly, the IHS is responsible for paying or authorizing payment for CHS if the AI/AN is a victim of a crime (see Section 2-3.24), unless:
- the AI/AN uis eligible for alternate resources, defined in Section 2-3.9G, or
- the AI/AN would be eligible for alternate resources if he or she were to apply for them, or
- the AI/AN would be eligible for alternate resources under State or local law or regulation but for the Indian's eligibility for CHS or other health services, from the IHS or IHS programs.
- Eligibility. The facility’s CHS Director must first determine whether the patient applying for CHS funds is eligible pursuant to Title 42 CFR §136.12 and §136.23. In addition, the facility’s CHS Director must determine that the medical services requested for payment from CHS funds are within medical priorities. The CHS program is not an entitlement program, therefore when funds are insufficient to provide the volume of CHS needed, priorities for service shall be determined on the basis of relative medical need (Title 42 CFR §136.23(e)). Before authorizing payment with CHS funds for services received by an eligible AI/AN patient the CHS Director, must:
- Ddetermine, upon reasonable inquiry, whether the patient is potentially eligible for alternate resources.
GUIDELINE: Based upon reasonable inquiry, the IHS should determine whether the patient applying for CHS is potentially eligible for alternate resources. Reasonable inquiry consists of ascertaining the patient’s household size, income, and assets, and applying alternate resource program standards to the patient’s information. Only patients who, upon reasonable inquiry, are determined to be potentially eligible for alternate resources are required to apply for such resources. The patients should not automatically be denied CHS benefits simply because of the possibility they might be eligible for an alternate resource.
- Advise the patient of the need to apply for alternate resources.
GUIDELINE: The IHS should provide the patient with a written notice that explains why it is necessary for him/her to make a “good faith” application to the alternate resource program. The notice should include information such as the availability of transportation to appointments, the need to schedule and attend appointments, and the importance of bringing the necessary documentation to the appointments. (See sample written notice, Manual Exhibit 2-3-A.)
- Assist the patient in applying, especially where it is evident that the patient is unable to apply or is having difficulty with the application process.
GUIDELINE: The Area or Service Unit shall include in its written notice that if a patient is unable to apply or is having difficulty applying for alternate resources, the CHS Officer or an individual from social services will assist the patient with the application process.
The Area or Service Unit shall include with the written notice an IHS-810 authorization form and an assignment of rights form for the patient to sign and return to CHS Officer. The IHS-810 form authorizes the IHS to obtain information from the alternate resource program files and allows the IHS to intervene on behalf of the patient to ensure completion of the application. (See Manual Exhibit 2-3-B.)
The CHS Officer or social services personnel will ensure everyone completes an alternate resource application during the intake process. Should the individual or the patient experience difficulty filling out the alternate resource application, either the CHS Officer or the social services personnel will assist the individual or the patient complete the alternate resource application. This practice is encouraged; however, the IHS should not deny CHS funds solely because an individual failed to fill out an alternate resource application before he/she received the needed medical services. This issue is most relevant in those States that have a limited retroactive eligibility rule.
fter determining that the patient is not eligible for CHS, the CHS Officer or social services personnel shall obtain the signature(s) of the individual(s) acknowledging that they are not eligible for CHS, e.g., not residing within the CHSDA.
When the CHS Officer or social services personnel determines an individual is not eligible for CHS, the CHS Officer or social services personnel shall assist the individual in completing the alternate resource application.
Each CHS Officer should document attempts to assist patients in applying for or completing an alternate resource application. This action is necessary to support a decision of whether or not to authorize payment from CHS funds.
The Area Office or Service Unit should attempt to pay for the medical services provided by utilizing alternate resource(s), then if no alternate resources are available, pay for the services provided, if the Indian is CHS eligible and if the alternate resource program denies payment of his/her medical bills for a valid reason, such as the patient is not a resident of the county or his/her income exceeds eligibility standards.
- Completed Application to Alternate Resource Program. The alternate resource program denies payment of the AI/AN patient’s medical bills for a valid reason, such as the patient is over income eligibility standards or not a resident of the county and the AI/AN is otherwise CHS eligible, the Area/Service Unit should pay the AI/AN patient’s medical bill. However, an AI/AN patient cannot be denied alternate resources that he/she would be eligible for under State or local law or regulation simply because he/she is eligible for the IHS and CHS programs.
If a completed application to an alternate resource program results in a denial because of the alternate resource’s policy that IHS should pay for on-reservation Indians, the IHS will pay the bill for the care provided and report the case to the respective regional attorney.
As specified in Title 42 CFR § 136.61, the IHS will no longer pay an AI/AN patient’s medical bills under protest because the patient refused to apply for alternate resources. It is essential that the AI/AN patient apply to the alternate resource program even if the alternate resource program denies payment of medical bills.
- Failure to Follow Alternate Resource Procedures. There are two instances when the IHS will not pay the provider for medical bills incurred by an otherwise CHS eligible patient:
- When the patient willfully or intentionally fails to apply or fails to complete an alternate resource application. If the IHS does not require its patients or beneficiaries, in “good faith,” to apply for and complete an alternate resource application, the alternate resource rule will have little effect on conserving contract health funds.
- The Director, CHS, will provide written notice to patients that if an alternate resource application is not completed, or if in 30 days the patient does not contact the CHS Officer for assistance in completing the application, then a CHS denial will be issued. If an alternate resource program issues a denial because the applicant failed to apply or failed to complete the application and the CHS file documents all attempts to assist the applicant, the CHS office should issue a CHS letter of denial to the patient and forward a copy to the provider.
- When the provider fails to follow alternate resource procedures, such as notifying the CHS program within specified time constraints, the IHS’ trust responsibilities include a requirement that providers maximize the availability of alternate resources. Thus, if the provider is not able to receive payment from an alternate resource program because of the provider’s failure to follow proper procedures, the IHS will not be responsible for the medical bill, even if the AI/AN patient is otherwise CHS eligible.
- Notice to Providers. The Director, CHS, will inform non-IHS providers (i.e., non-IHS facilities and practitioners providing medical services to IHS patients) of the CHS eligibility criteria and requirements. Such information can be provided through terms in a contract with the provider, by separate notice upon referral of a patient to the provider, or by general notification to a provider when there are ongoing referrals of patients to that same provider. The Director, CHS, will inform providers that:
- an IHS referral does not constitute a representation of eligibility under the CHS program;
- the IHS expects the provider to apply for alternate resources as it would for its non-AI/AN patients;
- the provider must investigate with each patient's, his or her eligibility for alternate resources and should assist the patient in completing necessary application forms; and
- if an alternate resource is available, its use is required and the IHS or FI shall be promptly notified of any payment received; and
- the IHS or FI will reject claims where the provider fails to investigate other party liability.
- Payor of Last Resort Rule. The use of alternate resources is specified in Title 42 CFR §136.61.
- An individual is required to apply for an alternate resource if there is reasonable indication that the individual may be eligible for the alternate resource.
- Refusal to apply for alternate resources when there is a reasonable possibility that one exists, or refusal to use an alternate resource, requires the denial of eligibility for CHS.
- An individual is not required to expend personal resources to meet alternate resource eligibility or to sell valuables or property to become eligible for alternate resources.
- Alternate Resources. Either an IHS or Tribal referral facility that is available and accessible to an individual but not in his/her area of residence. Alternate resources to pay for private sector services (non-IHS provided services) would include, but not be limited to, Medicare, Medicaid, Vocational Rehabilitation, Children’s Rehabilitative Services, private insurance, and State programs. The Victims of Crime Act of 1984 is not a acceptable alternate resource.
- Other Alternate Resources.
- A students whose grant includes funds for health services shall be required to use the grant funds to purchase available student health insurance.
- After alternate resources payment and when an alternate resource is identified that requires the IHS or Tribal program to pay a portion of the medical care costs, IHS Form 843-1A or comparable Tribal purchase order forms will be processed and distributed immediately to obligate the funds for the estimated balances. In these situations, IHS form 843-1A, must clearly indicate that payment will not be processed until the provider has billed and received payment from the alternate resource. It is proper and necessary to require either an explanation of benefits, or, in cases of denial from the alternate resource, a copy of the denial notice for the medical record.
- Exception to the IHS Payor of Last Resort: Tribal Self-Insurance Plans. The IHS is prohibited from seeking recovery when the health services provided to an eligible patient are covered by a self-insured health plan funded by a Tribe or Tribal organization under Section 206(f) of the IHCIA, P.L. 94-437, 25 U.S.C. §1621e(f). Consistent with congressional intent not to burden Tribal resources, the Agency has made a determination that tribally-funded self-insured health plans are not to be considered alternate resources for purposes of the IHS’ Payor of Last Resort Rule.
he decision not to treat Tribal self-insurance plans as an alternate resource is a narrow exception to the IHS’ Payor of Last Resort Rule consistent with congressional intent found in Section 206(f) of the IHCIA. Before a health plan is exempted from the Payor of Last Resort Rule requirements, the health plan must meet the definition of a Tribal self-insurance plan, as defined in this chapter, and include an exclusionary clause prohibiting payment if the patient is eligible for CHS.
- Alternate Resource. Tribal self-insurance plans without an exclusionary clause prohibiting payment to the IHS are considered to be an alternate resource and are subject to the IHS’ Payor of Last Resort.
- Verification. In order for a health plan to be exempted from the IHS’ Payor of Last Resort requirements, the coverage must meet the definition of a Tribal self-insurance plan. Documents needed to show that a plan is a Tribal self-insurance plan include:
- Documentation that describes how and from what resources the plan is funded.
- A copy of the self-insurance policy, with exclusionary clause clearly indicated.
- Refusal to Submit Documentation. If a Tribal health plan refuses to submit requested documentation, the IHS will not consider the plan to be a Tribal self-insurance plan. Plans that are not self-insured are considered to be an alternative resource and the Payor of Last Resort guidance is to be followed (See Section 2-3.7G).
- Procedures after Verification. After verification of a health plan as a Tribal self-insurance plan, the following procedures apply:
- Purchase orders are to be provided when a Service Unit issues a medical referral authorized by CHS for eligible AI/AN patients who are covered by the Tribal self-insurance plan with an exclusionary clause and otherwise meet the IHS CHS eligibility criteria.
- Purchase orders are to be issued when patients who are covered by a Tribal self-insurance plan receive emergency care at a non-IHS facility and that otherwise meets the IHS CHS eligibility criteria.
- Denials are to be issued when patients who are covered by a Tribal self-insurance plan self-refer without prior authorization to a non-IHS provider.
- Multiple Sources of Coverage Procedures. For purposes of this section, multiple sources of coverage refer to the situation where an individual who is covered by a Tribal self-insurance plan is also covered by private insurance and/or eligible for Medicare or Medicaid. In multiple eligibility situations, even if the Tribal self-insurance plan is not viewed by the IHS as an alternate resource, any other available private insurance, Medicare, and Medicaid are alternate resources as defined in 42 CFR §136.61 under the IHS’ Payor of Last Resort Rule. If a CHS claim is presented to the IHS for payment involving a dual eligible patient, the following procedures apply:
- Medicare and Tribal Self-insurance Eligible. If a patient is covered by both Medicare and a Tribal self-insurance plan (with an exclusionary clause) the IHS must issue a denial because Medicare is a primary payor to the IHS pursuant to 42 CFR §136.61. After Medicare has paid, if the criteria for CHS is met, the IHS may issue a purchase order for the payment of any remaining patient CHS liability.
- Medicaid and Tribal Self-insurance Eligible. If a patient is covered by both Medicaid and a Tribal self-insurance plan (with an exclusionary clause), the IHS must issue a denial because Medicaid is a primary payor to the IHS pursuant to 42 CFR §136.61.
- Private Insurance and Tribal Self-insurance Eligible. If a patient is covered by both a private insurance plan and a Tribal self-insurance plan (with an exclusionary clause) the IHS must issue a denial because private insurance is a primary payor to the IHS pursuant to 42 CFR §136.61. After private insurance has paid, if the criteria for CHS payment have been met, the IHS may issue a purchase order for the payment of any remaining patient CHS liability.
2-3.9 AUTHORIZATION FOR CHS
- Notification Requirements. The following notification requirements apply to all categories of eligible AI/AN patients including students, transients, and patients who leave the CHSDA. Notification requirements as described in 42 CFR §136.24 will be followed, including:
- No payment will be made for medical care services obtained from non-IHS providers or in non-IHS facilities unless the requirements listed below have been met and a purchase order for the care and services has been issued to the medical/dental care provider by the appropriate IHS ordering official.
- In non-emergency cases, an eligible AI/AN, an individual or agency acting on behalf of the patient, or the medical care provider, shall:
- prior to the provision of medical care services, notify the appropriate IHS ordering official of the need for services and supply information that the ordering official deems necessary to determine the relative medical need for the services and the individual’s eligibility.
- The requirement for notice prior to providing medical care services under this paragraph may be waived by the ordering CHS Service Unit CEO if the ordering official determines that providing notice prior to obtaining the medical care and services was impracticable or that other good cause exists for the failure to provide prior notice.
- In emergency cases, the patient, an individual or agency acting on behalf of the patient, or the medical care provider, shall, within 72 hours after the beginning of treatment for the condition or after the patient’s admission to a health care facility, notify the appropriate ordering official of the admission or treatment and provide information to determine the patient’s relative medical need for the services. The 72-hour period may be extended if the ordering official determines that notification within the prescribed period was impracticable or that other good cause exists for the failure to comply.
- Section 406 of the IHCIA P.L. 94-437, as amended, allows the elderly and disabled 30 days to notify the Service Unit’s CEO of emergency medical care received from non-IHS medical providers or at non-IHS medical facilities.
- The following definitions for an elderly and disabled individual are to be used until further defined and published in the FR.
- An elderly Indian means an AI/AN who is 65 years of age or older.
- A disabled Indian is an AI/AN who has a physical or mental condition that reasonably prevents him/her from providing or cooperating in obtaining the information necessary to notify the IHS of his/her receipt of emergency care or services from a non-IHS provider or non-IHS facility within 72 hours after the non-IHS provider begins to deliver medical services.
- Notification for Students, Transients, and Patients. Authorization for CHS for students, transients, and patients who leave the CHSDA will be the responsibility of the Service Unit from which the patient left except:
- When the individual is eligible for CHS in his/her current place of residence, except for full-time students as defined at 42 CFR §136.23(b)(i). For the purpose of this section, a patient’s area of residence is defined as the area where the patient currently resides, unless an exception applies such as the patient has moved to attend a university full-time. (See examples of clarification of the concept, Manual Exhibit 2-3-L.)
- If a CHS eligible patient presents to a Service Unit other than his/her Service Unit of residence for direct care and requires CHS, in this case, the Service Unit’s Director, CHS, will contact the patient’s Service Unit of residence for instructions for authorization or denying CHS. The patient will be informed that this is done or needs to be done by the treating facility. Payment for CHS is the responsibility of the patient’s area of residence in accordance with CHS regulations at 42 CFR §136.24, when notification is provided prior to the authorization and/or provision of CHS services that are referred out by a facility not in the patients area of residence. These guidelines do not preclude formal arrangement for fund transfers within or among Areas to provide CHS for patients from other Service Units.
- Payment. Payment for CHS shall be in made accordance with the provisions of the contract or purchase order and other provisions put forward in the IHS payment policy. Every effort must be made to ensure that the AI/AN patient, who is referred from an IHS or Tribal facility, is notified of his/her eligibility status for CHS prior to his/her referral time. In cases where determination of eligibility cannot be made before referral, the individual will be notified in writing prior to obtaining care that the IHS or Tribe may not be responsible for bills incurred.
- Patients Under Treatment at the Expiration of 180-Day Eligibility Period. Individuals under treatment that may be deferred to a later date will cease to be eligible 180-days after leaving their CHSDA. Individuals under treatment for an acute condition shall remain eligible as long as the acute medical condition exists. This requirement does not include continued treatment of chronic conditions, or, for example, obstetrical deliveries that occur after the 180-day period.
- Responsibility to Notify Indian Community of Requirements for Authorization. American Indian/Alaska Natives affected by the CHS program must be kept aware of policies and requirements for approving CHS payments for services, including the title(s) of the person(s) who must be notified when CHS is required. This notification will include, at a minimum, publication in local community and/or Tribal newspapers and posting of notices on bulletin boards in public patient areas of IHS or Tribal facilities. Changes in local policies or administrative requirements will be published and posted as outlined above and will be sent to providers commonly used by AI/AN patients, who may or may not have contracts with the Service Unit.
- Contract Health Services Authorization Numbering System. A uniform numbering system has been developed for use when the Service Unit is issuing IHS Form 843-1A purchase order documents. The use of this system will preclude two or more facilities from using the same document number and will assist in identifying the Area and facility.
- The number has four components and consists of 10 digits.
- The four components are: 00 0 00 00000.
- The first digit of the first component is always 0, followed by the last 2 digits of the FY being charged for the services. Example: the FY 2007 is 07.
- The second component is alphabetically coded to identify the Area. The alpha codes are:
- The third component consists of the 2-digit site code that identifies the facility being charged for the services. The 2 digits are the standard location code as used in the fiscal accounting system.
- The fourth component has 5 digits and is the sequential number for the documents to be charged to each is Service Unit facility. These numbers will begin each FY with 00001 and continue sequentially until the fiscal year's end. Service Unit supplemental authorizations, if necessary, will be numbered with the original numbers plus a Service Unit suffix of S-1, S-2, etc.
- The Service Unit staff will issue a new purchase order for any late or additional charges regardless of the FY.
- The CHS Authorization Flow Chart. The specific steps involved in a CHS purchase order from the initial request through processing and closeout are diagramed in Manual Exhibit 2-3-K. The flow chart provides an overview describing the process.
2-3.10 ELECTRONIC SIGNATURES
- Electronic Signature for CHS Purchase Orders. The “Electronic Signature Act,” P.L. 106-229, provides for the use of electronic signatures. The IHS is mandated to implement the electronic signature (E-SIGN) for the IHS CHS Management Information System. The electronic signature promotes the use of electronic contract formation, signatures, and record keeping in private commerce by establishing legal equivalence between:
- Contracts written on paper and contracts conveyed electronically;
- Pen and ink signatures and electronic signatures; and
- Other legally required written documents (termed “records”) and the same information in electronic form.
- Accessing Electronic Signature. This section establishes the guidance for the use of the electronic signature of IHS Form 843-1A in accordance with P.L. 106-229. Ensuring compliance with the Privacy Act, Health Insurance Portability and Accountability Act (HIPAA), and confidentiality requirements are the responsibility of each Area Contract Health Service Officer (CHSO). Contract Health Service staff will only be provided the ability to access the E-SIGN system if they have completed all security requirements and possess current procurement authority. The following are the guidelines for accessing the electronic signature within the Contract Health Services/Management Information System (CHS/MIS).
- Access to the electronic signature is accomplished through computer log-on at the local Service Unit and Area Office. It is the Area CHSO responsibility to ensure that the Privacy Act, HIPAA, and any confidentiality requirements are met prior to allowing staff to log on to the Resource and Patient Management System (RPMS) CHS/MIS.
- The Director, Office of Information Technology (OIT) is responsible for ensuring that the RPMS system is secure. Firewalls at each location site guard against unauthorized access.
- Procedures must be developed and implemented at each facility to ensure that RPMS access is revoked when employees leave CHS employment or are no longer eligible to access CHS information.
- Training of current or new staff will be provided by Area Office CHS staff via teleconferencing. Training will also be provided to current and new staff as changes and enhancements occur.
- Any problems or incidents related to CHS access or security must be reported to the Area CHSO.
- Training. The following staff training must be completed and documented:
- Health Insurance Portability and Accountability Act training. (The Area CHSO and the facility HIPAA Compliance Officer are responsible for scheduling and documenting training.)
- Office of Information Technology Training. (The Area CHSO is responsible for scheduling and documenting training.)
- Responsibilities. Before an individual can access the electronic signature for CHS the following responsibilities must be accomplished:
- Chief Executive Officer. The CEO will provide the Service Unit Site Manager with a delegation of procurement authority, including effective date and dollar limits.
- Service Unit Site Manager. The Service Unit Site Manager:
- will determine the appropriate parameters and assign “keys” for each individual.
- will revoke access if the sign-on and/or password are shared with other staff, contractors, or patients, regardless of the purpose.
- will notify the alternate “key” individual, by memorandum that he/she is assigned the authority to sign documents electronically, when the ”key” individual is unavailable.
- Individuals will keep the “key” information (individual sign-on and password) confidential.
- Procedures. The following procedures must be followed to access the CHS electronic signature.
- Access to the IHS Service Unit CHS/MIS through computer log on to the Service Unit RPMS.
- Access the CHS/MIS main menu and choose E-SIGN.
- Follow the prompts.
- Exit E-SIGN
2-3.11 CONTRACT HEALTH SERVICE PAYMENT DENIALS AND APPEALS
If a medical provider reasonably thinks that the CEO is a party to payment for services provided to an eligible patient, and if the a patient is denied CHS, both the provider and the patient must be notified in writing of the denial with a statement containing all the reasons for the denial. Refer to the CHS/MIS Manual (version 3.2) denial example.
- Denial Notice. A CHS denial notice must inform the patient/beneficiary/applicant that within 30 days from receiving the notice the patient/beneficiary/applicant:
- May request a reconsideration of the denial by the appropriate Service Unit CEO. However, the appeal must provide additional information previously not submitted.
- In accordance with Section 2-3.11(D), the applicant may appeal the original CHS denial by the CEO to the appropriate Area Director, if there is no additional information on which to base reconsideration. Requests for appeal may be submitted by a provider acting on behalf of the patient/beneficiary/applicant. In these instances, the Service Unit CEO must provide a response to the request to the provider with a courtesy copy of the response provided to the patient.
- May appeal the original CHS denial by the Service Unit CEO to the appropriate Area Director, if there is no additional information on which to base reconsideration.
- Failure to Follow Appeal Procedures. If the patient/beneficiary/applicant fails to follow these procedures, the request for reconsideration or an appeal may be denied. A written Notice of Denial will be sent to the patient/beneficiary/applicant stating there are no further appeal rights.
- Appeal Procedure. When, on appeal, the Area Director upholds the denial, the patient/beneficiary/applicant must be notified in writing of the denial and that an appeal may be submitted in writing to the Director, IHS, within 30 days of the date of the Area Director’s decision.
- Levels of Appeal. The IHS appeals process applies to IHS-administered CHS programs and those CHS programs administered under Title I and Title V that have negotiated and incorporated the IHS appeals procedures into their funding agreements. The CHS regulations currently in effect at 42 CFR §136.25 allow three levels of appeal:
- A request for reconsideration of the appeal by the Service Unit CEO,
- A request for appeal to the Area Director, and
- A final appeal to the Director, IHS.
- Tribal Appeals Process -Contractors. The IHS will conduct the appeal process for a tribally-managed CHS program because conducting the appeals process is a retained IHS function. A Tribe may not reduce or increase the level of appeals.
- Provide a written appeals process to the patient:
- negotiated and incorporated into the annual funding agreement;
- s comparable to the IHS appeals process; and
- is in accordance with the Administrative Procedures Act (5 U.S.C. 500, et seq.).
- Ensure that it has left sufficient resources with the IHS to conduct the appeal process. NOTE: It is not sufficient to have the IHS appeals procedures negotiated and incorporated into a Tribe’s funding agreement that the IHS appeals procedures will be used without fiscal evidence that sufficient funds have been withheld to pay for a Tribe’s appeals process.
- Tribal Appeals Process -Title I and Title V Programs. Title I and Title V programs that have negotiated and incorporated into their funding agreement provisions to use the IHS appeals procedures; agree to the following terms and conditions:
- The Area Director and the Director, IHS, will use the IHS regulations and interpretations, not Tribal criteria and interpretations, to adjudicate all CHS claims. Agency specified medical priorities and policies will be used to adjudicate Tribal CHS claims.
- The Title I or Title V programs shall provide necessary documentation required for claims adjudication. Depending on the nature of the claim, documentation such as medical records, date of notification, residency documentation, etc., could be required.
- The IHS conducts the appeals process for Title I and Title V programs without assuming any fiscal responsibility. When an Area Director, or the Director, IHS, overturns a Tribal denial of payment authorization, it is the responsibility of the Tribe not the IHS to pay for medical services incurred.
- Title I and Title V Program Denials of CHS Payment. Denials of CHS payment by Title I and Title V programs that do not use the IHS appeals process may not be appealed to an Area Director or the Director, IHS. Tribes that have assumed their own CHS appeals function are required to provide administrative procedures pursuant to the Indian Civil Rights Act of 1968 (25 U.S.C. 1301 et seq.). The Office of the General Counsel (OGC) advises that Title I and Title V health programs must make eligibility determinations in accordance with the IHS eligibility regulations in CFR, Title 42, Part 136. However, there are provisions of the IHS eligibility regulations that are subject to interpretation, and the Tribes are not required to interpret particular words in the regulations in the same way as the IHS. For example, Tribes and Tribal organizations may have a different definition of “close economic and social ties,” for CHS eligibility (see Title 42 CFR §136.23); thus, individual Tribal contractors and compactors make CHS eligibility determinations consistent with the IHS eligibility regulations at Title 42 CFR, Part 136. If the appeals process has been assumed by the Tribal contractor or compactor under P.L. 93-638, as amended, individuals who are dissatisfied with Tribal determinations of eligibility must pursue Tribal administrative remedies if the Tribe does not use the IHS appeal process. Tribes developing appeals policies and procedures need to consider the following:
- developing a formal appeals procedure and levels of appeal;
- establishing program policies concerning eligibility, medical priorities, referrals, and notification of all parties that clearly identify responsible parties; and
- protecting individual rights to due process.
- Chief Executive Officer. The CEO or his/her authorized designee is responsible for creating and maintaining a file on each CHS denial.
- Area Director. The Area Director or his/her authorized designee is responsible for the following:
- establishing individual patient-specific appeals files that contain all documentation in chronological order for all CHS appeals, and
- for forwarding copies of CHS appeals files to IHS Headquarters upon request.
- Information Copies. The Area Director, or his/her authorized designee, should not routinely forward information copies of all CHS denials to the Director, DCC. A file is to be sent only when requested by the Director, DCC.
- Executive Secretariat Staff, Office of the Director, IHS. The Director, Executive Secretariat Staff, will fax incoming controlled correspondence to the appropriate Area Director or his/her authorized designee.
- Area CHS Staff. The Area CHSO will analyze the controlled correspondence and submit all necessary documentation to the Director, DCC, within 10 working days of the date of the fax.
- The Director, DCC, must be notified if there were no appeals to the Service Unit’s CEO or the Area Director.
- Copies of all CHS determinations issued within the Area are to be submitted to the Director, DCC.
- If a CHS appeal or appeals are submitted to either the CEO or the Area Director, and the CEO or the Area Director has not issued a determination, a briefing memorandum shall be submitted to to the Director, DCC, in support of the actions taken.
- Appeals Process - Division of Contract Care. The Director, DCC, is responsible for processing all CHS appeals that will be sent to the Director, IHS. The Director, DCC, or his/her authorized designee, will:
- ensure that all required correspondence is included and is in chronological order;
- analyze and discuss issues in the appeal pertaining to the patient’s CHS, and process the appeal to the extent issues can be handled within established policy; and
- refer for review all CHS appeals that involve issues of medical judgment to the Director, Office of Clinical and Preventive Services; or
- refer for review all CHS appeals that involve issues requiring a legal opinion to the Director, Division of Regulatory Affairs, Office of Management Services, prior to being forwarded if necessary, to the OGC.
- Final Decision. The decision of the Director, IHS, shall constitute the final administrative action in the CHS appeals process.
- Appeal File. The CHS appeal file shall contain:
- all CHS denial letters, briefing documents, or memorandums prepared in connection with any recommendation to the CEO or the Area Director regarding such denial;
- all correspondence to the IHS from the representative of the patient/beneficiary/applicant/claimant;
- any other relevant documentation, i.e., correspondence, maps, bills, or receipts; records of telephone calls to or from the patient/beneficiary/applicant/claimant or the claimant’s representative; and
- correspondence relative to any inquiry (i.e., congressional, State, etc.) made on behalf of the claimant and pertinent correspondence relative to prior appeal by the same claimant.
- Retention Period. Each CHS appeal file will be maintained wherever the response was initially received. The CHS appeal file records must be retained at the Service Unit, Area Office, and/or HQ for a period of 6 years and 3 months after the IHS CHS appeals process has been exhausted. After the 6 years 3 month period has elapsed, the records may be destroyed. If the CEO of the Service Unit where the CHS appeal files are located makes a decision to keep the records longer e.g., per a court order, the records may be sent to the National Archives and Records Administration.
2-3.13 MANAGEMENT OF CHS FUNDS
- Commitment Register. Management of CHS funds in accordance with the FMFIA requires that the CHS Commitment Registers are maintained at each authorizing location. A CHS Commitment Register must contain the following minimum information (See Manual Exhibit 2-3-H):
- Date of Authorization
- Authorization Number.
- Provider Name.
- Patient Name.
- Date of Service.
- Allowance Amount.
- Estimated Cost of Service.
- Balance of Funds.
- Contract Health Service Fund Status Report. The CHS fund status report is to be submitted to the Area Financial Management Office at least once a month. A summary of the CHS fund balance shall be provided to the CEO, the Clinical Director, and the CHS Committee at least once a month.
NOTE: The summary of the CHS fund balance may also be provided to the Tribal Health Director.
- Services Authorized That Working Day. An entry will be made on the commitment (document control) register for each obligation of funds, or modification of funds, or adjustment to obligation of funds. Commitment entries will be made daily to reflect the services authorized during that working day. Commitment entries must be completed within 5 working days from the date of referral or notification of services provided.
NOTE: This function can be performed electronically or manually.
- Electronically. The CHS RPMS package performs these functions and should be used when available.
- Manually. The CHS Commitment (document control) Register is used when the CHS RPMS package is not available.
2-3.14 FOLLOW-UP OF OUTSTANDING AUTHORIZATIONS
Each Service Unit shall establish a follow-up system for all CHS authorizations that have not been completed and returned to the Service Unit for action within 90 days of issuance. Manual Exhibit 2-3-G provides a recommended form letter for use in these circumstances.
2-3.15 RECONCILIATION OF COMMITMENT REGISTER
The CHS Commitment Register is reconciled monthly with the official financial management report, throughout the fiscal year. The recommended procedures for reconciliation of the Commitment Register are provided in Manual Exhibit 2-3-I.
2-3.16 DATA REPORTING
The appropriate workload and fiscal codes are entered into the data system, as specified in the FR dated January 22, 1992, (57 FR 2642), and Core Data Set requirements.
2-3.17 CATASTROPHIC HEALTH EMERGENCY FUND
- Background. The Indian Health Care Amendments of 1988, P.L. 100-713 established the CHEF solely to meet the extraordinary medical costs associated with treating of victims of disasters or catastrophic illnesses who are within the responsibility of IHS and Tribal programs.
The Appropriations Act directs that the CHEF shall not be allocated, apportioned, or delegated to an Area Office, Service Unit, or any other basis.
Effective FY 1993, the Federal Medical Care Recovery Act (FMCRA) funds were returned directly to the Service Units, pursuant to Section 207 of the IHCIA; the funds are no longer added to the CHEF.
The term “catastrophic illness” refers to conditions that are costly by virtue of the intensity and/or duration of their treatment. Cancer, burns, high-risk births, cardiac disease, end-stage renal disease, strokes, trauma-related cases such as automobile accidents and gunshot wounds, and certain acute mental illnesses are examples of conditions that frequently require multiple or prolonged hospital stays and/or extensive treatment post-discharge.
The IHCIA Amendments of 1987, P.L. 100-713, authorizes the IHS CHEF program and requires the IHS to publish regulations governing the program. Until such time as regulations are published, the Headquarters CHEF guidelines currently in place will continue to serve as the interim policy governing the CHEF program for all CHS programs. For specific details on the CHEF, reference the current, annually issued CHEF guidelines.
- Use of CHEF Funds. The CHEF resources are expended according to the CHS requirements and while CHEF funds are available they are to be used to partially reimburse IHS direct and tribally contracted programs for patient expenditures that would qualify for the CHEF program.
Obligations against the CHEF in excess of $50,000 will be made only in cases where the local CHS management document that it is medically and fiscally inappropriate to transfer the patient to an IHS, Tribal, or less costly contract provider.
All requirements for alternate resources must be met before reimbursement can be made from the CHEF. The CHEF reimbursements shall be applied only to cases that have been reviewed and approved by the CHEF Manager; any amounts not used because of payments by alternate resources or cancellations must be returned to the Headquarters CHEF account. For specific details on the CHEF, reference the current, annually issued CHEF guidelines.
- Cost Threshold. The CHEF threshold is adjusted by the Director, IHS, within the range established by law. The Director, DCC, will provide instructions to the Director, IHS, regarding fluctuations in the CHEF cost threshold annually. Whether a case meets the CHEF cost threshold amount is determined by only including those costs remaining after payment has been made by Federal, State, local, private health insurance, or other applicable alternate resources.
2-3.18 FISCAL INTERMEDIARY
- Purpose. The purpose of the FI is to operate a nationwide centralized medical and dental claims processing and payment system to:
- collect, compile, and organize workload and financial data; and
- provide statistical and financial reports to the IHS for the administration of its CHS program.
- Service Class Codes. Service class codes indicate the type of service that is provided in an IHS facility, i.e., inpatient, ambulatory, emergency, laboratory services, dialysis, X-ray, dental, etc. The CHS funds are used to pay non-IHS providers who come to the IHS facility and provide their services there. For example, a cardiologist who comes every other week to a facility and sees patients. This is particularly beneficial in isolated locations as it means that patients who lack transportation are able to obtain the care for which they are eligible. The FI pays the following service class codes:
[The object class code conversion table is in Manual Exhibit 2-3-J. This table provides a crosswalk between the IHS service class codes (SCC) and the IHS health accounting system’s object class codes.]
21.85 Patient and Escort Travel. Includes travel and related costs, e.g., lodging, meals, etc.
25.2A Medical Lab Services-Outpatient Non-IHS. Includes laboratory costs for outpatients at non-IHS contract facilities. If pathologists and lab fees are invoiced together use cost center 25.2A. Excludes pathologist's professional fee invoiced separately using cost center 25.4D.
25.2B Medical Lab Services-Inpatient and Outpatient IHS Facility. Includes all laboratory costs for inpatients and outpatients at IHS facilities referred to contract facilities Excludes pathologist’s professional fee invoiced separately using cost center 25.4C.
25.2D Dental Laboratory. Includes dental prosthetic fabrication services provided by dental laboratories. Excludes any dentist professional fee using cost center 25.4E.
25.2G Non-Federal Hospitalization. Includes inpatient services in non-Federal hospitals. (The other Federal Agency is the VA and we have service agreements with the VA.)
25.2H X-ray Services-Outpatient Non-IHS. Includes x-ray services for outpatients at non-IHS contract facilities. If radiologist and facility fees are invoiced together, use cost center 25.2H. Excludes radiologist’s professional fee invoiced separately using cost center 25.4D.
25.2J X-ray Services-Inpatient and Outpatient IHS. Includes all radiology costs for inpatients and outpatients at IHS facilities referred to contract facilities. Excludes radiologist’s professional fee invoiced separately using code 25.4C.
25.2L Hospital Outpatient. Includes ambulatory services at contract hospitals other than emergency room (ER) services. Excludes any physician professional fee billed separately using code 25.4D.
25.2Q Emergency Room Services. Includes non-IHS hospital ER services. Includes any ER physician fees whether combined or billed separately.
25.2R Dialysis. Contract Hospital Inpatient Services FY 1991 and prior FY only.
25.2S Physical Therapy Services. Includes all contract therapy services invoiced separately. Excludes all physician professional fees using code 25.4D.
25.4A Physician-Inpatient-IHS Facility. Includes contract physician services for patients hospitalized in IHS facilities. Includes radiologist and pathologist professional fees, invoiced separately.
25.4B Physician Inpatient-Non IHS Facility. Includes all physician services for patients hospitalized in non-IHS facilities.
25.4C Physician-Outpatient-IHS Facility. Includes all contract physician services for outpatients in IHS facilities. Includes radiologist and pathologist professional fees, invoiced separately.
25.4D Physician Outpatient-Non-IHS Facility. Includes all physician services for outpatients in non-IHS facilities and physician offices.
25.4E Dentists. Includes all services provided by contract dentists to inpatients and outpatients. Includes combined dental laboratory costs and dental services.
25.4G Fee Basis Specialist-IHS Facility. Includes all consultant services other than physician services. Examples are nurse anesthetists, audiologists, speech therapists, podiatrists, and dental hygienists using cost centers 268 and 368.
25.4J Fee Basis Specialist-Non-IHS Facility. Includes all consultant services in non-IHS facilities other than physician services. Examples are: nurse anesthetists, audiologists, dental hygienists, and podiatrists.
25.4L Refractions-IHS-Non-IHS Facility. Eye and vision exams only, not for injuries or other medical reasons, by ophthalmologists and optometrists.
25.4M Extended Care Facilities. Includes rehabilitation facilities, skilled nursing facilities, psychiatric inpatient facilities; and psychiatric inpatient care in an acute facility exceeding 30 days. Excludes any physician fee using cost center 25.4D.
25.2N Dialysis-Physician Outpatient and Inpatient Services in IHS Consumable Medical and Surgical Supplies. Includes medical, dental, and surgical supplies. Examples are dressings, bandages, and catheters.
26.3A Consumable Medical and Surgical Supplies. Includes medical, dental, and surgical supplies. Examples are dressings, bandages, and catheters.
26.3G Non-consumable Medical and Surgical Supplies. Includes rental and purchase of wheelchairs, apnea monitors, oxygen tanks, beds, etc.
26.3K Eyeglasses. Includes eyeglasses and repair to eyeglasses. If eyeglasses are billed with the professional fee use cost center 26.3K.
26.3L Hearing Aids. Includes costs of hearing aid devices and repairs to hearing aids.
- Authority. The authority for the use of a fiscal agent is contained in P.L. 99-272, the Consolidated Omnibus Budget Reconciliation Act of 1985, Section 17003:
“...provides authority for the Secretary of the Department of Health and Human Services to contract with fiscal agents to perform claims payment, processing and audit function with respect to services purchased on a contract basis by the Public Health Service .... Fiscal agents must either be entities which could qualify as carriers for Medicare purposes, or Indian Tribes of Tribal organizations acting under Indian Self-Determination Act contracts. While the fiscal agents need not be Medicare carriers, they must meet the same requirements as Medicare carriers regarding efficiency and effectiveness of operations, surety bonds, and financial controls.”
- Fiscal Intermediary Operations. A listing of the payment by type of service the FI processes payments on are listed by object class code in Manual Exhibit 2-3-J. For a description of the FI internal operations information refer to the most current version of the FI Reference Manual for IHS/CHS. The FI Reference Manual is updated to reflect changes or incorporate information on an as-needed basis.
- Accessing the FI Data System. The IHS is required to protect patient medical information from all security risks. Changes to the FI data system allowing data access and the ability to communicate through local area networks shall include provisions to ensure and safeguard patient confidentiality. Ensuring compliance with the Privacy Act, HIPAA privacy regulations, and confidentiality requirements is the responsibility of each Area CHSO. Each IHS employee, unless otherwise authorized, is responsible for limiting access to patient medical information to strictly direct need to know in the provision of patient care as defined in the IHS mission statement. The following steps provide necessary guidance for FI data system access:
- Access to FI data is accomplished through computer log-on to the IHS Intranet at the OIT in Albuquerque, New Mexico.
- The Director, OIT, is responsible for ensuring that the FI data systems are secure. Firewalls established at each site guard against unauthorized access.
- Each IHS site must ensure that Intranet access to the FI data system is revoked when an employee ceases to have a direct involvement in CHS on a day-to-day basis.
- Employee access to the FI data system can be revoked for a violation of the security requirements.
- Access may be revoked for reasons other than a violation of the security requirements if requested by IHS officials.
- Each authorized user of the FI data system will have an individual sign-on and password assigned. It is the responsibility of each user to keep this information confidential. Access must be revoked if the sign-on and password are shared with other staff members regardless of the purpose.
- A walk-through will be provided by IHS and FI staff via teleconferencing for new users. Updates will also be provided to current staff as changes and enhancements occur.
- All problems or incidents must be reported to the Area CHSO.
- Fiscal Intermediary Access Procedures. In order for access to the FI data system to be granted, the following procedures must be followed:
- Access Requests. The Area CHSO will submit the form to the FI staff. (See Manual Exhibit 2-3-C.)
- Access Set-Up. The FI staff will receive approved requests and will assign sign-on and passwords.
- Access Training. The FI staff is responsible for contacting the CHS employee granted access to the FI data system with their assigned sign-on and password. The FI staff will provide a practical orientation and ongoing user support for new users via teleconferencing.
- Access Log. The FI staff will maintain a log of all users of the FI data system. Reports will be sent to the designated IHS FI Project Officer, as requested.
- Other Reports. The FI staff will provide reports to the FI Project Officer as requested. These reports include information about who accessed the system, how often, and whose access was revoked.
- Audit Conducted Prior To Implementation of the Data System. If the FI conducted an audit prior to implementation of the FI data system. The FI continues to monitor CHS access.
2-3.19 MEDICAL AND DENTAL PRIORITIES
- Medical Priorities. The application of medical priorities is necessary to ensure that appropriated IHS/CHS funds are adequate to provide services that are authorized in accordance with IHS approved policies and procedures. (See Manual Exhibit 2-3-D.)
- Dental Priorities. See Manual Exhibit 2-3-E.
2-3.20 DEFERRED SERVICES
- Recording and Reporting. The reporting formats and guidelines for deferred services accrued and deferred services expenditures are sent to the Areas by the Director, DCC, on an annual basis.
- Guidelines. Guidelines for recording and reporting on deferred services cases must meet these criteria:
- The patient must have accessed the IHS health care system during the FY reporting period. Although there will be no carry over in reporting deferred services from one year to the next, the Service Unit has the option to pay for care deferred in a prior FY.
- Deferred services must be elective (i.e., “deferrable”), not emergent or urgent. Payment denials for care received that was not within stated medical priorities are reported through the denial reporting process, not as a deferred service.
- The service required cannot be accessible or available to the patient in the IHS direct care system (care provided directly in IHS or tribally-operated clinics or facilities, not CHS care) within the usual and customary treatment and referral patterns.
- The deferred service must be within IHS medical priorities. Items listed in the IHS medical priorities as procedures that the IHS will not pay for cannot be reported as a deferred service.
2-3.21 CONTRACT HEALTH SERVICES MANAGED CARE
The purpose of managed care is to promote access to needed health care at the most affordable cost, maximize utilization of resources and alternate resources, and support greater continuity of care. To that end, each Service Unit shall maintain the following elements to review and monitor care referred for clinical and financial case management. Priority cases should be high-cost and high-risk cases. All Service Units will maintain the following elements to review and monitor the referral and expenditure of CHS funds:
- Contract Health Service or Managed Care Committee. There shall be an active CHS or managed care committee (MCC) to review CHS referrals and emergency cases. Each Service Unit will establish MCC policies and procedures that define the purpose of the committee; the membership; and the roles and functions of the members, e.g., benefits coordination, continuity of care, referrals, and follow-up needs.
- Membership. Members should include, at a minimum, the Clinical Director, Director of Nursing, or Clinical Manager (or other primary care provider), Utilization Review Nurse (if available), Administrative Officer, and the CHS Specialist.
- Meetings. Meetings must be held at least once a week to determine the appropriateness of referral requests for expenditure of CHS funds.
NOTE: When an inquiry is being made by a relative of a committee member the committee member must recuse himself or herself from case discussion and decisions. The record of the meeting must reflect the reason that the employee removed his or herself from the case. An employee with procurement authority must not sign the purchase or delivery order for a patient to whom he or she is related.
- Criteria for Payment Decisions. The committee will consider the following criteria, at a minimum, for CHS cases:
- The care must be within medical priorities.
- Funds must be available.
- The requested services must not be accessible or available in an IHS or Tribal facility.
- The patient must be CHS eligible.
- The CHS referral shall be made to the appropriate provider based on cost or quality factors, or an exception justified.
- For a review of emergency cases, the care provided shall be verified by the committee as an emergency situation.
- Care must not be deferred for cases where full reimbursement through alternate resources is available.
- Minutes. Minutes will be maintained to accurately reflect the decisions, actions, and determinations taken for each case discussed.
- High-Cost Cases. The MCC will monitor high-cost cases (greater than $10,000), including the progress of each case, according to current Area guidelines for high-cost case management.
2-3.22 THE CHS "5-DAY" RULE
Section 220 of the IHCIA directs the CHS program to issue a purchase order or a denial within 5 days of notification of a CHS claim. Section 220 states the following:
“The Service shall respond to a notification of a claim by a provider of a contract care service with either an individual purchase order or a denial of the claim within 5 working days after the receipt of such notification.
If the Service fails to respond to a notification of a claim in within 5 working days, the Service shall accept as valid the claim submitted by the provider of a contract care service.
The Service shall pay a completed contract care service claim within 30 days after completion of the claim, in accordance with the Prompt Payment Act 31 U.S.C. 3901.
If a patient is potentially eligible for an alternate resource, issue a denial and advise and assist the patient in the application process.” (See Manual Exhibit 2-3-N.)
2-3.23 THIRD PARTY TORTFEASOR CASES AND FMCRA
- Definition. Third-party tortfeasor cases are cases where the IHS provides or pays for services to an injured individual where a third-party (the Tortfeasor) may be found to be responsible for the injury. (See IHS Circular No. 2006-02, “Reporting Third-Party Tortfeasor Claims and Recovery of Funds under the Federal Medical Care Recovery Act.”
- Claims. Under the FMCRA the Federal Government is authorized to recover the cost of these services. The various offices of the Regional Attorney are responsible for asserting any Government claim under the FMCRA. The OGC advises that the procedure of withholding payment on purchase orders pending resolutions of third-party liability...does not follow the procedures for recovery under FMCRA. Bills submitted to the IHS where CHS have been authorized in a third-party case must be paid if otherwise valid and funds are available. Payment is not to be withheld pending final determination of any claim the patient may have against a third-party.
- Alternate Resource. In addition, authorization of CHS may not be denied based on any theory that potential recovery from an alleged third-party Tortfeasor constitutes an “alternate resource” under the CHS regulations.
- Recovery. Any funds recovered by the Federal Government must go back to the respective CHS Program. All recovered FMCRA funds are returned to the CHS program that originally paid for the services provided to the patient. Applicable reporting and payment requirements are mandatory and must be followed.
- Cost of Services Settlement. There is a positive motivating factor that should be kept in mind. Failure to report FMCRA cases could possibly harm the patient or the patient’s family. If the injured party should make a settlement that does not reflect the cost of services provided by the IHS, the Federal Government might still have claim against the settlement for the cost of services. Though it is problematic whether the Federal Government would pursue its claim in such a situation, the possibility cannot be totally discounted. Therefore, prompt reporting can act to protect the interest of the injured party.
- Third-Party Report Forms. All possible third-party Tortfeasor cases are to be promptly reported to the CHSO. All third-party report forms should be completed by the Service Unit CHS staff and contain the following information:
- Patient Name.
- Date of Service, explanation of situation.
- Name of third-party responsible for payment in the case.
- Costs paid by IHS.
- Any related correspondence.
2-3.24 VICTIMS OF CRIME ACT
The Victims of Crime Act of 1984,Title 42, Chapter 112 U.S.C., established a crime victim compensation program. The program is operated by the Federal Government and provides compensation to criminal violence victims and survivors of criminal violence, including drunk driving and domestic violence for medical expenses attributable to a physical injury resulting from a compensable crime, and for certain other expenses. Accordingly the IHS CHS program must pay for care provided to eligible AI/ANs before the crime victim compensation program pays; consequently, the crime victim compensation program is an exception to the IHS payer of last resort policy.