a. |
Snyder Act. The Snyder Act (25 U.S.C. 13, November 2, 1921) provided the authority to assist "Indians throughout the United States for relief of distress and conservation of health." In 1921 Congress initially gave this authority to the Bureau of Indian Affairs (BIA), Department of the Interior.
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b. |
Transfer Act. The Transfer Act, Public Law (P.L.) 83-568, transferred the authority for health care of Indians to the Public Health Service on August 5, 1954.
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c. |
Indian Health Care Improvement Act. The legislative base for authorization to collect from private insurance is contained in the Indian Health Care Improvement Act, P.L. 94-437,
Amendments of 1988. Title IV, Sections 4.01 and 402, provide Medicaid and Medicare authority with reference to the Social Security Act, particularly Section 1880 of that law which contains the authority for IHS to collect from Medicare. Section 1913 of the Social Security Act contains the authority for IHS to
collect from Medicaid.
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d. |
Core Data Set Requirements. On January 22, 1992, the final
notice of the Core Data Set Requirements established by the Director,
IHS, was published in the Federal Register (Vol. 56, Number 14)
establishing a set of core program data elements that all IHS programs
and facilities are required to submit for the IHS national data base.
The Core Data Set requirements fulfill several purposes, including meeting the management information needs of IHS and tribal contractors (P.L. 94-437, as Amended, 925 U.S.C. 1662, Section 602). The PRS core data set requirements include reporting record formats and guidelines on the use of the Social Security Number (SSN) as a patient identifier.
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(1) |
Develops General Policies. Establishes general policies regarding administration of the PRS program in IHS.
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(2) |
Maintains Area Standards of Performance. Establishes standards of performance for Area operations for patient registration.
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(3) |
Conducts Data Accuracy Evaluations. Management control reviews and quality assessment mechanisms are utilized by the HCA to assess the overall data accuracy of each Area. The HCA makes determinations as to the types of data collection and reporting needed, and recommends improvements.
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(4) |
Evaluates Overall Program. The HCA assesses the effectiveness of the PRS at the Area Offices and the service units. The long-term purpose and direction of the PRS is continuously evaluated by the HCA to ensure maximum effectiveness in meeting the health needs of IHS beneficiaries.
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(5) |
Develops Plans. The HCA develops long-term plans and objectives for continuous improvement of the PRS in consultation with appropriate agencies and tribes.
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(6) |
Provides Staff Assistance on Policy Issues. The HCA is responsible for providing staff assistance to the Area offices in matters of general policies and procedures regarding patient registration. The training for Area office staff is coordinated by the HCA.
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(1) |
Providing Technical Staff Assistance and
Training. The ASM is responsible for providing and coordinating technical staff assistance and training to the service units for the day-to-day operation and utilization of the PRS. Within regulations, policies, procedures, and budgets established by IHS Headquarters, the ASM shall develop and recommend overall policies and methods for the technical direction, control, review, and evaluation of the Area and service unit PRS.
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(2) |
Establishing Service Unit Standards of
Performance. Develops and recommends standards of performance for the service units' operation of the PRS.
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(3) |
Evaluating Service Unit Programs.
Reviews and evaluations of the patient registration program at service units shall be conducted by the ASM to ensure high-quality service delivery and system functions. Reviews and evaluations conducted shall be consistent with methodology developed by the HCA, OHP.
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(4) |
Providing Advice on Patient Registration Issues. The ASM shall be responsible for identifying opportunities for improvement of the PRS and advising IHS Headquarters on suggested policy, procedural, and/or technical changes.
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(5) |
Monitoring Data Accuracy. The ASM monitors and updates submissions from field facilities, and informs the data center and IHS Headquarters of problems or suggestions for improvement.
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B. |
Contract Health Service Delivery Area (CHSDA). The CHSDA is the geographic area within which contract health services will be made available to the members of an Indian community who reside in the area. The CHSDA is determined by: reservation boundaries; counties that include all or part of a reservation; and any county or counties that have a common boundary with a reservation; or States that are designated as a CHSDA (for example: Alaska, Nevada, and Oklahoma).
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C. |
Indian. A person of Indian descent designated by a tribe as being Indian, residing in the Continental United States; and Indians, Aleuts, and Eskimos in Alaska.
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D. |
Indian Health Programs. The health services program for Indians administered by the IHS within the Department of Health and Human Services.
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E. |
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 to Indians because of their status as Indians.
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F. |
Reservation. Any federally recognized Indian tribe's reservation, pueblo, rancheria, or colony, including former reservations in Oklahoma, and Alaska Native regions established pursuant to the Indian Allotment Acts and the Alaska Native Claims Settlement Act.
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G. |
Tribe Codes. A three digit numerical code assigned to each tribe that is officially recognized by the Federal Government.
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H. |
Tribally Operated Programs. The health care programs which are managed by the tribes according to the legal provisions, which encourage eventual Native American control over their own health care system. The Indian health programs in some states are entirely tribally operated (for example: California.) Other States have a mixture of these and IHS programs.
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(1) |
General Eligibility Criteria for Direct Care. Services will be made available, as medically indicated, to persons of Indian descent who belong to the Indian community serviced by the local IHS facilities and program. The IHS may provide an individual with health services if the community in which he/she lives regards him/her as an Indian.
In accordance with the current law, IHS may use such factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active participation in tribal affairs, or other relevant factors in keeping with general BIA practices in the jurisdiction. However, it should be the patient's responsibility to obtain appropriate BIA documents.
In case of doubt as to whether an individual applying for care is within the scope of the program, the service unit director (or designee) shall obtain information from the appropriate BIA or tribal official in the pertinent jurisdiction regarding' the individual's continuing eligibility.
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(2) |
Pregnancy. Services will be made available, as medically indicated, to a non-Indian woman pregnant with an eligible Indian's child, but only during the period of her pregnancy through postpartum (generally about six weeks after delivery, unless the provider determines there are pregnancy induced health care problems that do not resolve by six weeks.)
In cases where the woman is not married to the eligible Indian under applicable State or tribal law, paternity must be acknowledged in writing by the Indian or determined by order of a court of competent jurisdiction.
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(3) |
Disease Control. The service unit must provide medically indicated services to non-Indian members of an eligible Indian's household if the medical officer in charge determines it is necessary to control an acute infectious disease, or if it presents a public health hazard.
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(4) |
Emergency Care. If the patient's condition is such that immediate care and treatment are necessary to prevent danger to life or limb, services must be provided even while pending notification of eligibility.
A medical record will be made for all patients receiving emergency care. If the pending identification does not confirm the patient as an Indian beneficiary, billing can be done after the emergency care is received.
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(5) |
Priorities for Care. Priorities for care and treatment will be determined on the basis of relative medical need. Access to other arrangements for obtaining the necessary care will also be a determinant, because the IHS is the "payor of last resort" after the patient has utilized his alternative/third party resources and benefits.
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(1) |
Name *. The patient's full legal name must be entered in the PRS preceding each visit, otherwise duplicate records may be generated. Check for different name spellings to ensure that the patient does not already have a health record number. Names cannot be changed unless legal documentation is provided by the patient.
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(2) |
Health Record Number *. Each patient should have only one health record number at a facility or service unit. When entering this number in the system, check for an exact match within the files of the facility.
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(3) |
Date of Birth *. The date of birth is one of the field identifiers from the patient file that is used to search for potential duplicates. Verify the date of birth to ensure there are no different entries that would imply different patient files. If the 'official' Social Security date of birth is in error, assist the patient in notifying the Social Security Administration (SSA) to make a correction. Date of birth should not be changed unless the patient provides a birth certificate or other certified legal document. Otherwise, use of the
wrong date of birth will generate an error report.
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(4) |
Sex *. This notation would be either 'F' for female or 'M' for male This is one of the field identifiers used to search for potential duplicate files.
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(5) |
Social Security Number (SSN). For all persons ages two and above it is strongly encouraged that they have a SSN, according to IRS requirements. Therefore, all patients are strongly encouraged to obtain a SSN for their children at birth. Application forms for obtaining a SSN can be provided to patients.
Even though having a SSN is not mandated, it is extremely beneficial in identifying patient records. If possible, maintain a photocopy of the Social Security card in the patient's record at each facility where he is treated to verify the SSN. This number must be recorded accurately because it is a major identifier of the patient for third-party billing. Use of "pseudo numbers" will generate error reports.
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(6) |
Tribe of Membership/Tribe Codes *. The list of recognized tribes is already in the Patient Registration
System to be accessed in order to match and update the tribe of
membership information provided by the patient.
It is important to obtain verification of tribal membership, proof of Indian descent, and to maintain a photocopy of the certificate in the patient's record, or maintain a verified notation regarding the page of the tribal documents that indicates the individual's membership.
The complete listing of tribe codes is in the User Guide/Standard Code Book Tables (Vol. II.) May 24, 1991, provided by the data center in Albuquerque, New Mexico.
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(7) |
Indian Blood Quantum
*. The actual blood quantum fraction of the patient must be entered into the PRS as verified with BIA documents. Since membership in a tribe is important to eligibility for CHS, a notation regarding verified blood quantum will be made in the Patient Registration System. (Making an entry in this PRS field is required to continue in the database as it is presently structured.)
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(8) |
Present Community/Community of Residence *. This refers to the community in which the patient currently resides, and may not be the same as the mailing address. Be sure to indicate when the patient moved to their present community because official residence affects CHS eligibility.
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(9) |
Beneficiary Code *. This is the primary classification under which this patient qualifies for IHS care. Until the present law is amended, patients are usually qualified because they possess Indian blood.
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(10) |
Eligibility Status *. The types of
eligibility for the patient will be determined based on the accuracy of
the various data entered in the Patient Registration System.
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(11) |
Veteran Status *. Verify, if possible, the
veteran status of the patient. This is important to determine potential
eligibility for other services. Veteran information may include items
such as: branch of service; service entry date service separation date;
and Veterans Administration medical care eligibility.
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A. |
Patient Registration Data/Cornerstone for Patient Health Care Programs.
The information generated through the PRS forms the cornerstone for the entire facility and IHS-wide data base. All of the other IHS RPMS automated systems key off the patient registration information from each facility (service unit), because it is transmitted to the Division of Data Processing Services (DDPS), Albuquerque, New Mexico, for national reporting. Therefore, it is vital that the PRS information is current and accurate.
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B. |
Federal Managers Financial Integrity Act (FMFIA) Compliance. Headquarters (HCA), Area offices, and service units must document policies and practices - that allow management to effectively monitor the PRS in accordance with the requirements of the FMFIA. A formal Management Control System (MCS), must be developed by the HCA, OHP, and approved by the IHS Management Control Officer (the Associate Director, Office of Administration and Management), and implemented by the HCA. The MCS provides coverage for complete and current IHS policies and procedures for the PRS, the conduct of regularly scheduled reviews of all PRS operations at all IHS Areas and services units, and continuous improvements to the IHS PRS.
The Associate Director, OHP, Chief, HCA, and IHS Patient Registration Coordinator at Headquarters, as the PRS Management Control Area Managers, shall develop a MCS that:
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(1) |
Focuses on Continuous Quality Improvement. The quality
improvement process shall ensure that management systems and policies
for the PRS are basically positive and effective. This includes
completing policies and procedure revisions to improve service and
quality outcomes that meet customer (client and patient) needs.
Continuous quality improvement in the PRS concerns the interface of
functions across departments and services. The focus is on determining
how the system itself can continue to be user friendly, and its
effectiveness improved through the active involvement and participation
of staff from all organizational components.
Emphasis must be placed on a proactive (preventive), not reactive, action, and on concurrent not retrospective evaluation. This is a different orientation from being problem focused and addressing problems after they have been identified and caused system complications.
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(2) |
Maintain a Systematic Approach. The success of the continuous improvement process is due to the concurrent focus on all segments of the organization. This results in an improved patient service. The continuous improvement process has a positive impact on
the PRS.
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(3) |
Patient Service/Sensitivity.
It is important that all IHS staff are sensitive to IHS patients cultural values and concerns for privacy. Patient registration is a vital part of each IHS facility's public relations program and patient registration staff should receive continuous management support for maintaining skills in communicating with the patients and assuring the patients' comfort during the interview process.
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(4) |
Privacy Act of 1974. Confidentiality of patient information collected must be maintained at all times in accordance with the Privacy Act of 1974. The registration staff must periodically review the Privacy Act.
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(5) |
Program Integrity. The integrity and accuracy of the patient registration data base is necessary because it is the core of many IHS systems and has a direct effect on many IHS applications requiring workload and population data. All third-party, information (Medicare, Medicaid, and private insurance) for patient must be accurate.
This information assists the Area Offices in collecting third party revenue for eligible patients who are treated in IHS and contract facilities.
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A. |
User's Guide. The IHS Patient
Registration User's Guide (Vol. I-II), published May 24, 1991, by the DDPS in Albuquerque contains explanations of the various types of reports published by the data center (Vol. I) and the various code lists (Vol. II).
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B. |
User's Manual. The IHS Patient
Registration User's Manual, by the Office of Information Resources Management in Albuquerque contains detailed directions for the users of the PRS in the service units.
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C. |
User's Guide Addendum. The IHS Patient
Registration User's Guide Addendum contains modifications to support the
SSN collection, as well as other information. The SSN will be the major
identifier for patients in the PRS.
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D. |
IHS Patient Registration Examples. The IHS Patient Registration Examples published by the Division of RPMS in Albuquerque gives visual examples of the various computer screens in the PRS. This is of great assistance to technical staff working directly with the systems in the service units.
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E. |
Business Office Manual. An excellent source
of information on the overall functions of the PRS is the Business
Office Manual. The three-ring-binder format provides for easy additions of new information regarding patient business services and is continually updated to reflect system changes and modifications. The Business Office Manual developed by the Headquarters Strategic Initiative Team Office of Health Programs. The chapters on patient registration contain updates on the automated PRS.
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