To delegate to the greatest degree possible, within the limits of available funds, authority for the operation of the CHS Program to Area Directors and the Service Unit Directors, (SUD)

To clarify and explain CHS policies and procedures for Public Law (P.L.) 93-638, the Indian Self-Determination and Education Assistance Act, contractors, when applicable.

To further explain the Code of Federal Regulations Title 42, Sections 36.21 through 36.25. However, this manual should not be cited as authority for making decisions on eligibility or payment denials. The CFR is the proper citation for correspondence to providers and American Indian and Alaska Native patients.

 

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, the CHS Commitment Register
CDSR - Core Data Set Requirement 
FMCRA - Federal Medical Care Recovery Act 
FMFIA- Federal Managers' Financial Integrity Act 
FI - Fiscal Intermediary 
IHCIA - Indian Health Care Improvement Act 
IHS - Indian Health Service 
P.L. - Public Law 
PRO - Peer Review Organization 
SU - Service Unit 
SUD - Service Unit Director 
U.S.C. - United States Code

 

Alternate Resources - Health care resources other than those of the IHS. Such resources include health care providers and institutions, and 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, Medicaid), State and local health care programs and private insurance.

Appropriate Ordering Official - The person, with documented procurement authority, who signs the purchase order authorizing CHS payment.

Area Director - The Director of an IHS Area designated for purposes of administration on IHS programs.

Catastrophic Health Emergency Fund - The fund to cover the IHS portion of medical expenses for catastrophic illnesses and events falling within IHS responsibility.

Contract Health Service Delivery Area - The geographic areas within which CHS will be made available by the IHS.  (Reference Federal Register, vol. 49. No. 6, 1984)

Contract Health Services - Health services provided at the expense of the IHS from other public or private providers (e.g., dentists, physicians, hospitals).

Contract Health Services Eligible Person - A person of Indian descent belonging to the Indian community served by the local IHS facilities and program who resides within the United States (U.S.) on a reservation located within a Contract Health Service Delivery Area, (CHSDA); or resides within a CHSDA and either is a member of the tribe or tribes located on that reservation; or maintains close economic and social ties with that tribe or tribes.

The definition of eligibility for CHS shall be consistent with Sec. 2-3.7 (E)(b) infra.  If there is a misunderstanding, Sec. 2-3.7(E)(2)(b) will prevail to resolve the issue.

Contract Health Services to Support Direct Care - These are provided within 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 the IHS facility.  Examples of direct care services that cannot be reimbursed with CHS funds are on-call hours, after hours or weekend pay, and holiday coverage.  (e.g., for x-ray, laboratory, pharmacy).

Emergency - Any medical condition for which immediate medical attention is necessary to prevent the death or serious impairment of the health of an individual.

Fiscal Intermediary - The fiscal agent contracted by IHS to provide and implement a system to process CHS medical and dental claims for payment.

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 U.S. to Indians, because of their status as Indians.

Reservation - Any federally recognized Indian tribe's reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. 1601 et seq.), and Indian allotments.

Residence - In general usage, a person "resides" where he or she lives and makes his or her home as evidenced by acceptable proof of residency. In practice, these concepts can be very involved. Determinations will be made by the SUD based on the best information available, with the appeals procedure process as a protector of the individual's rights.

Secretary - The Secretary of Health and Human Services and any other officer or employee of the Department to whom the authority involved has been delegated.

Service - The Indian Health Service.

Service Unit Director - The Director of an IHS service unit designated for purposes of administration of IHS programs.

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 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.

 

The CHS funds are used to supplement and complement other health care resources available to eligible Indian people. The funds are utilized in situations where: (1) no IHS direct care facility exists, (2) the direct care element is incapable of providing required emergency and/or specialty care, (3) the direct care element has an overflow of medical care workload, and (4) supplementation of alternate resources (i.e., Medicare, private insurance) is required to provide comprehensive care to eligible Indian people.

 

Headquarters.

Establish general policies regarding the administration of the CHS program in the IHS.

Establish standards of performance for Area, SU, and Fiscal Intermediary (FI) operations of CHS.

Assess the performance of the CHS program at Area, SU, and FI against established standards.

Assess long-term purpose and direction of the CHS program to ensure maximum effectiveness of the program in meeting the health needs of Indian people.

Develop 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 Division of Resources Management to Area Directors.

Promptly and appropriately respond to appeals of denials of CHS by IHS Area Offices.

Provide guidance in the establishment of 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 Catastrophic Health Emergency Fund (CHEF).

Establish general guidelines and policies for applying managed care practices and CHS quality assurance activities in the Areas/SUs.

Responsible for establishing and implementing 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 the Indian Health Manual, Part 5, Chapter 16, "Management Control Systems."

Area Offices.

Within regulations, policies, procedures, and budget, develop and establish policies and methods for the direction, control, review, and evaluation of the Area and SU CHS programs.

Establish medical priorities for the care of eligible Indian people that will most effectively meet their needs within the funds available.

Maintain records for planning and for controlling funds and furnish reports to Headquarters as required.

Coordinate the Area CHS program to allocate an equitable share of funds among the SUs.

Establish contracts in cooperation with SUDs 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 Indian Health Manual, Part 5, Chapter 5, Section 13, "Acquisition of Health Care Services."  Provide assistance to P.L. 93-638 programs with these activities as requested/required.

Coordinate appropriate contract activities with the Contracting Officer.

Periodically review and evaluate the services provided under contract to ensure quality and effectiveness. In carrying out this responsibility, Areas are encouraged to utilize the services of one or more peer review organizations established under P.L. 92-603, Social Security Amendments of 1972.

Act on appeals of SU denials, whether issued by a SUD or a comparable official for P.L. 93-638 operated CHS programs, promptly and appropriately.

Monitor the CHEF cases submitted by the Area SUs 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/SUs.

Responsible for internal controls related to the FMFIA.

Service Units/Tribally Operated Programs.

Determine whether an individual requesting services is eligible within established guidelines.

Provide CHS by following the medical priority guidelines that are consistent with Area and Headquarters IHS medical priorities.

Process all requests for CHS including the. issuance of purchase orders, determination of alternate resource availability, and maintenance of all financial records.

Ensure program/budget control and effective utilization of CHS funds at SU level.

Work closely with appropriate Area Office staff in identifying need for CHS and in negotiating contracts with hospitals, clinical services, dentists, and other health care providers.

Conduct managed care activities through an established CHS managed care committee that reviews and monitors CHS referrals and emergency cases.

Monitor and prepare CHEF cases according to high cost case management guidelines.

Ensure that procedures and policies comply with the FMFIA.

CHSDAs

The approved CHSDAs are specified in 42 CFR 36.22, and may be changed only in accordance with the Administrative Procedures Act (5 U.S.C. 553).

Established CHSDAs 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, Santa Cruz, Kern, Merced, Monterey, Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura.

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, the Congress statutorily creates or redesignates CHSDAs through legislative enactments such as appropriations, restoration and/or recognition acts, public laws, etc. This information is distributed through public issuances as necessary.

Redesignation of CHSDAs.

Request for redesignation of CHSDAs may be initiated by the tribal group(s) affected, or by IHS, after participation with the affected tribal group(s).

All requests for redesignation must provide the following information:

The estimated number of Indian people who will be included and/or excluded for eligibility of CHS.

The tribal governing body's designation of the categories of Indian people to be included and/or excluded from eligibility for CHS; i.e., (1) members of the tribe who live near the reservation; (2) Indian people who are not members of the tribe but have close economic and social ties with the tribe. Please note that redesignation of CHSDAs 'may not result in the exclusion of Indian people eligible under 42 CFR 36.23(a)(l), i.e., reservation residents. Generally, it is expected that an expansion in the CHSDA will not exceed counties that border the current CHSDA. All CHSDAs must be within the U.S.

The estimated costs of including additional Indian people in the CHSDA as determined in accordance with the IHS resource allocation guidelines currently in effect.

The impact of the change in the CHSDA on the level of CHS being provided to eligible Indian people in the original CHSDA.

The justification for the change in the CHSDA. The justification may include criteria used in establishing the CHSDA for the States of Oklahoma, Nevada, Michigan, and Minnesota outlined in 42 CFR 36, page 34650, items 10, 11, and 12, but are not limited to these criteria.

Submission of a Proposed CHSDA Change

The Area will analyze the proposal outlining positive and negative features, and will recommend acceptance or rejection over the signature of the Area Director to the Director, IHS. Proposal for change in a CHSDA will be submitted to Headquarters, Attention: Chief, CHS Branch, for appropriate action.

The CHS Branch will review the request for redesignation of the CHSDA, and apply the criteria. outlined in Paragraph 2 above to the information submitted to support the request.

After review, the CHS Branch shall make findings as to whether the criteria has been met and recommend whether the request for redesignation should be granted.

The regulations at 42 C.F.R. -36.22(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, redesignate 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 redesignation, but the IHS publishes as well a notice with requests for comments as part of the consultation process.

If after determining that a redesignation of a tribe's CHSDA should be made, the IHS shall publish a notice with request for comments in the Federal Register advising the public that the IHS proposes to redesignate a particular tribe's CHSDA.

The notice with request for 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 date of publication of the notice.

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 a review of any comments received by the IHS after publication of its notice with request for comments, and after determining that the tribe's CHSDA should still be redesignated, the IHS shall publish a final notice advising the public that the IHS is redesignating a particular tribe's CHSDA.

The change in the CHSDA will be effective on the date of the final notice in the Federal Register.

Counties may be added to a tribe's CHSDA by operation of the CHS regulations when (a) the IHS inadvertently or mistakenly omitted the county from the tribe's CHSDA list; or (b) 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. Under these circumstances, the notice and comment process described above, in paragraphs (2) through (5), is not necessary.  Instead, a memorandum from the IHS Director is mailed to the respective IHS Area Director regarding the action resulting in a correction to, or expansion or creation of, the tribe's CHSDA with instructions to the Area Director to contact the tribe with this information.

There is no authority to provide payment for services under the CHS program unless funds are, in fact, available.

The CHS funds are limited to services that are medically indicated. See Exhibit 2-3-A for services that may be included and those specifically excluded.

The CHS may not be expended for services that are reasonably accessible and available at IHS facilities.

The determination as to an IHS/tribal facility being," reasonably accessible and available" is a service unit/tribal health director decision based on the following criteria:

Determination of the actual medical condition of the patient, i.e., emergent, urgent, or routine.

The ability of the IHS/tribal facility to provide the necessary service.

The level of funding available to provide CHS.

Distance from the IHS/tribal facility.

The following guidelines will be used in applying the above, criteria:

The CHS funds may be authorized for an emergency to the extent that the contract facility was the nearest available provider capable of providing the necessary services and the patient's condition dictated that he/she be transported to the nearest hospital. 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.

Tribal Health Directors may consult with available IHS Chief Medical Officers, medical staff, or contract providers in order to arrive at an administrative decision.

Medical and dental priorities (Exhibits 2-3-A+B) 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 qualified IHS professionals.

Final decision as to classification of medical services as "emergency" will be based on review by an IHS/tribal physician 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 an IHS professional, can best be met by using a contract facility and sufficient CHS funds are available for this level of service.

Routine health services (neither emergent nor urgent) should ordinarily be provided by IHS staff and facilities.  Routine health service may be provided through CHS when the SUD 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 facility capable of providing these services is within 90 minutes one-way surface transportation time from the person's place of residence until level of IHS funding permits a less restrictive guideline.

Each SU must develop a SU policy, with tribal participation, on the availability and accessibility of IHS facilities. This policy will be posted and published to maximize knowledge among the American Indian and Alaska Native populations served.

The CHS funds may be expended for services to individuals treated in an IHS/tribal facility to the extent that the individual is eligible for direct services.  However, Hospitals and Clinics funds shall be used to support direct care whenever possible. The payment of costs for "contract to support direct care" services (e.g., prenatal, podiatry, or orthopedic clinics) provided within the facility are permitted when patients are under the direct supervision of an IHS/tribal physician or a contract physician practicing under the auspices (authority) of the IHS/tribal facility. Service in a non-IHS direct or tribal facility are not included unless the patient meets CHS eligibility criteria of 42 CFR 36.23, "Persons to whom contract health services will be provided."

Eligibility.

To be eligible for CHS, an individual must:

Reside within the U.S. and on a reservation located within a CHSDA; or

Reside within the U.S., and

within a CHSDA, and

be a member of the tribe or tribes located on that reservation or maintain close economic and social ties with such tribe or tribes.

The basis for determining close economic and social ties are established by:

employment with a tribe whose reservation is located within a CHSDA in which the applicant lives;

marriage to, or being a 'child of (see Section 2-3.7 (5)e, below), an eligible member of the tribe or

determination by the tribe, including certification from the tribe or tribes near where they live that they have close economic and social ties with the tribe whose reservation is located within a CHSDA in which the applicant lives.

An Indian claiming eligibility for CHS has the responsibility to furnish the SUD or the tribal program with documentation to substantiate the claim.

Be a student or transient.

Boarding School Students CHS is provided during their full-time attendance, by the Area where the boarding school is located, while the student is in attendance at all Bureau of Indian Affairs (BIA) boarding schools, including the following BIA off reservation schools: Flandreau Indian School, Moody County, South Dakota; Wahpeton Indian School, Richland County, -North Dakota; Sherman Indian High School, Riverside County, California; Maricopa County, Arizona; Riverside Indian School, Caddo County, Oklahoma; and Chemawa Indian School, Marion County, Oregon. Boarding school students can receive CHS whether or not they resided in a CHSDA before attending the school.

While the student is on a scheduled break or vacation, the student's CHS permanent area of residence is responsible for payment of CHS services.

The CHS will be made available to students and transients who would be eligible or CHS at the place of their permanent residence within a CHSDA, but who are temporarily absent from their residence, as follows:

College (undergraduate and graduate) vocational, technical, or other academic education. The SU where the student was eligible for CHS prior to leaving for school is responsible for the student. While the student is on a scheduled break or vacation, the student's CHS permanent area of residence is responsible for payment of CHS services.

Transients (persons who are in travel or are temporarily employed, such as seasonal or migratory workers), during their absence from their place of residence.

Other persons outside the CHSDA.  Persons who leave the CHSDA in which they are eligible for CHS, and are neither students nor transients, will be eligible for CHS for a period not to exceed 180 days from such departure.

Other Eligibility Considerations:

An Indian is not required to be a citizen of the U.S. to be eligible for CHS. The Indian (e.g., Canadian or Mexican) must reside in the U.S. and be a member of a tribe whose traditional land is divided by the Canadian border (i.e., St. Regis Mohawk, Blackfeet) or Mexican border (i..e.Tohono O'Odham).

Section 709(b) of the Indian Health Care Improvement Act, until such time as any subsequent law may otherwise provide, states that the following California Indians shall be eligible for health services provided by the Service:

(1) any member of a federally recognized Indian tribe; (2) any descendent of an Indian who was residing in California on June 1, 1852, but only if such descendent - (A) is living in California, (B) is a member of the Indian community served by a local program of the Service, and (C) is regarded as an Indian by the community in which the descendent lives; (3) any Indian who holds trust interests in public domain, national forest, or Indian reservation allotments in California; and (4) any Indian in California who is listed on the plans for distribution of assets of California rancherias and reservations under the Act of August 18, 1958 (72 STAT. 619), and any descendent of such an Indian. Section 709(c) 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.

Indians adopted by non-Indian parents must meet all CHS requirements to be eligible for care (e.g., reside in a CHSDA).

Foster/Custodial Children - Indian 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 of the Indian Health Care Improvement Act, P.L. 94-437, as amended, states in part: "(a)(l) 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 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. (2) 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."

A non-Indian woman pregnant with an eligible Indian's child who resides within a CHSDA is eligible for CHS during pregnancy through post partum (usually 6 weeks). If unmarried, such a woman is eligible for CHS if an eligible Indian male states in writing that he is the father of the unborn child or such is determined by order of a court of competent jurisdiction. This will ensure health services to the unborn. Indian child.

A non-Indian member of an eligible Indian'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 or an acute infectious disease, which constitutes a public health hazard.

Priorities for CHS.

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 IHS medical priorities are found in Section 2-3.17. Tribal programs are required to follow IHS regulations and can utilize Section 2-3.17 priorities as guidelines.

Area-wide priorities should be established to ensure an equivalent level of services in all SUs, taking into consideration the availability and accessibility of IHS/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 SU basis, shall be made known to the Indian population being served through publication in local community and/or tribal newspapers and posting of notices on bulletin boards in patient areas of IHS/tribal facilities.

Payor of Last Resort - 42 CFR 36.61

The IHS is the payor of last resort of persons defined as eligible for CHS under these regulations, notwithstanding any State or local law or regulation to the contrary.

Accordingly, the IHS will not be responsible for or authorize payment for CHS to the extent that:

The Indian is eligible for alternate resources, defined in paragraph (c), or

The Indian would be eligible for alternate resources if he or she were to apply for them, or

The Indian 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.

The payor of last resort rule does not represent a change in the CHS program requirements. The CHS office must first determine whether the patient applying for CHS funds is eligible pursuant to 42 CFR 36.12 and 36.23 (1986).  In addition, the CHS office must determine that the medical services requested for payment from CHS funds are within medical priorities. The CHS program is not an entitlement program and thus, when funds are insufficient to provide the volume of CHS needed, priorities for service shall be determined on the basis of relative medical need (42 CFR 36.23(e) (1986)).

Upon application by an Indian patient for CHS the CHS offices must:

Determine, upon reasonable inquiry, whether the patient is potentially eligible for alternate resources.

GUIDELINE:   Initially, the IHS should make a determination based upon reasonable inquiry whether the IHS 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 IHS patients who, upon reasonable inquiry, are potentially eligible for alternate resources are required to apply for such resources. The IHS 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 the patient's need to make a "good faith" application to the alternate resource program. The notice should include information such as the need to schedule and attend scheduled appointments, the necessary documentation to bring to the appointments, and availability of transportation to appointments. (See sample written notice, Appendix 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/SU should include in its written notice that if a patient is unable to apply or is having difficulty applying for alternate resources, the CHS office or social services wi11 assist with the application process.

The Area/SU should include with the written notice an authorization to release and an assignment of rights form for the patient to sign and return to CHS. These forms authorize the IHS to obtain information from the alternate resource program files and allows IHS to intervene on the patient's behalf to ensure completion of the application. (See Appendix 2-3-B.)

In some areas, the CHS offices or social services assist the patient in completing an alternate resource application prior to an illness or injury. This policy should be encouraged; however, the IHS should not deny CHS funds for an individual's failure to apply prior to medical need. This issue is most relevant in those States that have a limited retroactive eligibility rule such as Arizona where Arizona Health Care Cost Containment System has a 48-hour retroactive eligibility rule.

Some CHS offices obtain the signatures of individuals acknowledging that they are not eligible for CHS, e.g., not residing within the CHSDA. This policy should continue with an additional requirement that when the CHS office determines an individual is not CHS eligible, the CHS office should assist the individual in completing the alternate resource application.

Each CHS office should document attempts to assist patients in applying for or completing an alternate resource application. Documentation of assistance for application to the alternate resource program is necessary to support a decision whether to authorize payment of CHS funds.

Completed Application To Alternate Resource Program.

If a completed application to the alternate resource program results in denial of payment of the Indian's medical bills and the Indian is otherwise CHS eligible, the Area/SU should pay the Indian's medical bill if the alternate resource program denied payment for a valid reason such as: over income eligibility standards or a non-resident of the county; i.e., the Indian is determined non-eligible for the same reasons that a non-Indian would be determined non-eligible.

If a completed application to an alternate resource program results in a denial for a McNabb-type reason (the program denied because of an alternate resource-type rule of its own or based on a policy that IHS should pay for on-reservation Indians), the IHS will pay the bill and report the case to the regional attorney.

Under the old regulations, a completed alternate resource application was not required when the file was well documented that an application to the alternate resource program would prove futile. An application to the alternate resource program was determined to be futile when the program had an alternate resource-type rule of its own or a policy that IHS should pay because the patient was Indian. In these instances, the CHS office paid the Indian patient's medical bills, under protest.

Pursuant to the new rule as coified at 42 CFR 36.61, the IHS will no longer pay the Indian patient's medical bills under protest. It is essential that the Indian patient make application to the alternate resource program even if the program denies payment of medical bills because IHS is considered an alternate resource. The IHS clarified its alternate resource rule to specifically designate the IHS payor of last resort, notwithstanding a State or local rule to the contrary. Thus, the IHS will deny payment of the medical bill pursuant to its payor of last resort rule, and inform the medical provider that payment must be sought from the alternate resource program.

Failure To Follow Alternate Resource Procedures

There are two instances when IHS will not pay the provider for medical bills incurred by an otherwise CHS eligible Indian patient.

First, when the patient willfully or intentionally fails to apply or fails to complete an alternate resource application. If IHS does not require its 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.

This policy is supported by the 9th Circuit decision in McNabb, supra. The court interpreted the IHS policy of requiring a patient to first make application to the alternate resource program as "serving a legitimate government goal of efficient distribution of limited resources." The court recognized the fact that contract care funds are limited and thus application to an alternate resource program results in more Federal funds being available to meet the needs of other Indians.

The Area/SU should provide written notice to patients that if an alternate resource application is not completed, or if the patient does not contact the CHS office for assistance in completing the application within 30 days of the date of the notice, then a CHS denial letter 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 is well documented with attempts to assist the applicant, the CHS office should issue a CHS denial to the patient and a copy should be forwarded to the provider.

Second, the IHS will not pay the provider when the provider fails to follow alternate resource procedures, such as not notifying the program within its time constraints. The IHS trust responsibilities include requiring the providers to 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 Indian patient is otherwise CHS eligible.

The SU should inform non-IHS providers (i.e., non-IHS facilities and practitioners providing medical services to IHS beneficiaries) 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 continuous referrals of patients to that same provider.. The IHS should inform providers that: (1) an IHS referral does not constitute a representation of eligibility under the CHS program; (2) the IHS expects the provider to apply for alternate resources as it would for its non-Indian patients; (3) the provider must investigate with each patient, his or her eligibility for alternate resources and should assist the patient in completing necessary application forms; (4) if an alternate resource is available, its use is required and the IHS or FI shall be promptly notified of any payment received; and (5) the IHS or FI will reject claims where the provider fails to investigate other party liability.

The use of alternate resources is mandated by IHS Payor of Last Resort Rule, 42 C.F.R. 36.61 [1990].

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 for health services to meet alternate resource eligibility or to sell valuables or property to become eligible for alternate resources.

Examples of alternate resources are those resources, including IHS/tribal facilities, that are available and accessible to an individual. Alternate resources would include, but not be limited to, Medicare, Medicaid, vocational rehabilitation, Veterans Administration, crippled Children's programs, private insurance, and State programs.

Other Alternate Resource Information

Students whose grant includes  funds for health services shall be required to use the grant funds to purchase available student health insurance.

When an alternate resource is identified that will require the IHS/tribal program to pay a portion of the medical care Costs, the appropriate IHS forms (IHS-43, 57, or 64) will be processed immediately to obligate the funds for the estimated balance, after alternate resource payment, with corresponding distribution of the form. In these situations, the IHS forms (IHS-43, 57, or 64) must clearly indicate that payment will not be processed unless and until the provider has billed and received payment from the alternate resource. It is proper and necessary to require either an explanation of benefits (EOB) or, in cases of denial from the alternate resource, a copy of the denial notice for the record.

Notification requirements as described in the Federal Register of August 4, 1978, and contained specifically in 42 CFR 36.24, will be followed, including but not limited to:

No payment will be-made for medical care and services obtained from non-service providers or in non-service facilities unless the requirements listed below have been met and a purchase order for the care and services has been issued by the appropriate IHS ordering official to the medical care provider.

In non-emergency cases, an eligible Indian, an eligible non-Indian, [or] an individual or agency acting on behalf of this person, or the medical care provider shall, prior to the provision of medical care and 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 and services under this paragraph may be waived by the ordering official if the ordering official determines that giving of 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, an eligible Indian, an eligible non-Indian, an individual or agency acting on behalf of this person, or the medical care provider shall, within 72 hours after the beginning of treatment for the condition or after admission to a health care facility, notify the appropriate IHS ordering official of the admission or treatment and provide information to determine the 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 0f P.L. 94-437, as amended, allows the elderly and disabled 30 days to notify the IHS of emergency medical care received from non-IHS medical providers or at non-IHS medical facilities. The following definitions for elderly Indian and disabled Indian are to be used until further defined and published in the Federal Register.

An elderly Indian means an Indian who is 65 years of age or older.

A disabled Indian is an Indian 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-service provider or facility within 72 hours after the non-service provider began to deliver the care.

Notification requirements apply to all categories of eligible persons including students, transients, and persons who leave the CHSDA.

Authorization for CHS to students, transients, and persons who leave the CHSDA will be the responsibility of the SU from which the person left except:

When the individual is eligible for CHS in his/her current place of residence.

If a CHS eligible patient presents to a CHS Area/SU other than the permanent Area/SU for direct care and requires CHS, the Area/SU will contact the patient's Area of record for instructions for disposition of the patient.  Payment for CHS is the responsibility of the extent of regulation, when notification is provided prior to the authorization and/or provision of CHS services by another IHS Area.  If the patient's Area of record is not notified prior to the referral or within 72 hours for emergencies, the referring SU is responsible for payment. These guidelines do not preclude formal arrangement for fund transfers within or among Areas to provide CHS for patients from other service units.

For the purpose of this section of the manual a patient's permanent area of record 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-I.)

Payment shall be in accordance with the provisions of the contract or purchase order and other provisions put forward in the payment policy.

Persons Under Treatment at the Expiration of 180-Day Eligibility Period.

Individuals under treatment for a condition that may be deferred to a later date will cease to be eligible at the expiration of the 180-Day period after leaving their CHSDA.  Individuals under treatment for an acute condition shall remain eligible as long as the acute medical condition exists.

This does not include continued treatment of chronic conditions, or for example, obstetrical deliveries that occur after 180-Days.

Responsibility to Notify Indian Community of Requirements for Authorization.

Indian people affected by the CHS program must be kept aware of policies on administrative requirements for approval of CHS payment for services, and the title(s) of the person(s) who will be notified when CHS is required.  This notification will include at least publication in local community and/or tribal newspapers and posting of notices on bulletin boards in patient areas if the IHS facilities.  Changes in local policies or administrative requirements will be published and posted as outlined above including notification to vendors commonly used by Indian people who may or may not have contracts with IHS.

The Indian person being referred from an IHS/tribal facility will be notified at referral time of his/her eligibility status for CHS.  In cases where determination of eligibility cannot be made before referral, the individual will be notified in writing that the IHS/tribe may not be responsible for bills incurred.  See Exhibit 2-3-C.

CHS Authorization Numbering System.

A uniform numbering system has been developed to use when issuing IHS-43/64 purchase 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 digit of the fiscal year being charged for the services.  Example:  Fiscal Year 1998 is 08.

The second component is an alpha code to identify the Area.  The alpha codes are:

Aberdeen       C         Navajo        N
Alaska            A         Oklahoma   O
Albuquerque   Q         Phoenix       X
Bemidji           D         Portland       P
Billings            B         Tucson         S
California        L          Nashville     U 

The third component consists of the two digit fiscal code that identifies the facility being charged for the services.  The digits are standard location code as used in the Fiscal Accounting System.

The fourth component has five digits and is sequential number for the documents to be charged to each issuing facility.  These numbers will begin each fiscal year with 00001 and continue sequentially for the year.  Supplemental authorizations, if necessary, will be numbered with the original numbers plus a suffix of S-1, S-2, etc.

The CHS Authorization Process, Flowchart - The flow of a CHS purchase order for from initial request through processing and closeout is diagramed in Exhibit 2-3-H.  Many aspects of CHS and other activities are incorporated in this general flow.  The flow chart provides a general description of the process.

If a person is denied CHS, or when a medical provider may reasonably think that IHS is a party to payment, both the patient and the provider must be notified in writing of the denial with a statement containing all the reasons for the denial.  Refer to the CHS/Management Information System manual (version 2.0) denial package.  The notice must inform the applicant that within 30 days from the receipt of the notice the applicant:

May request a reconsideration by the appropriate SUD/Tribal Health Director and that a request for reconsideration must contain additional information not previously submitted.

In accordance with Section D may appeal the original denial by the SUD/Tribal Health Director to the appropriate Area Director, if there is no additional information on which to base reconsideration.

Appeals may be submitted by providers.  The provider will be considered as acting on behalf of the patient.  A response must be made to the provider and a courtesy copy of such response is provided to the patient.

When on appeal, the Area Director upholds the denial, the 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.

If the claimant fails to follow procedures, the request for reconsideration of an appeal may be denied.  A written Notice of Denial will be sent to the claimant.

The IHS appeals process applies to IHS administered CHS programs and to Title I and III programs that have negotiated and incorporated into their funding agreements that the IHS appeals procedures will be utilized.

The CHS regulations currently in effect at 42 CFR 36.25 (1986) only allow three levels of appeal:  (a) request for reconsideration of the appeal by the SUD/Tribal Health Director or other individual or group designated by the tribe, (b) appeal to the Area Director, and (c) final administrative appeal to the Director, IHS.

Tribal contractors that have decided to utilize the IHS appeals process are required to operate their program in accordance with IHS regulations.  Tribes may not reduce the level of Appeals.  A tribe cannot require a claimant to submit an additional appeal not provided in the regulations.  However, a tribe may have a request for reconsideration submitted to the CHS office (e.g., tribal health director: that issued the denial or to a committee of the tribe.  The committee of the tribe would fulfill the role of 'SUD' and thus, the process would be consistent with the scheme provided in the CHS regulations.

Title I and III programs that have negotiated and incorporated into their funding agreement that the IHS appeals procedures will be utilized agree to the following terms and conditions:

The Area Director and the Director, IHS utilizes the IHS', not tribal criteria and interpretations, to adjudicate claims.  The IHS utilizes its medical priorities and policies to adjudicate IHS CHS claims.

The Title I or III program shall provide necessary documentation required for claims adjudication.  Depending on the nature of the claim, documentation such as medical records, date of notification, papers pertaining to residency, etc., could be required.

The IHS reviews the appeals from Title I and III programs without assuming any fiscal responsibility.  When an Area Director, or the Director, IHS, issues a determination overturning the tribal denial of payment authorization, it is the responsibility of the tribe not the IHS to pay the bill.

The tribe must have left sufficient funds with the IHS before either an Area Director or the Director, IHS, may adjudicate a claim.  It is not sufficient to have it negotiated and incorporated into a tribe's funding agreement that the IHS appeals procedures will be utilized without withholding sufficient funds to pay for the costs to operate the appeals process for a tribe.

Denials of CHS payment by Title I and Title III programs that do not utilize the IHS appeals mechanism may not be appealed to an Area Director or the Director, IHS.  Tribes that have assumed the 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) had advised that Title I and Title III health programs must make eligibility determinations in accordance with the IHS eligibility regulations in the Code of Federal Regulations (CFR), Title 42, Part 36.  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 contract health service eligibility (See 42 CFR 36.23.).  Thus, eligibility determinations will be made by the individual tribal contractors and compactors consistent with the IHS eligibility regulations at 42 CFR Part 36.  Under P.L. 93-638, as amended, individuals who are dissatisfied with tribal determinations of eligibility must pursue tribal administrative remedies.  Issues that need to be considered by tribes i the development of appeals policies and procedures include:  (1) development of a formal appeals procedure and levels:  (2) establishment of clear program policies concerning eligibility, priorities, referrals, and notification of all parties, and (3) protection of individual rights to due process.

The SUD, or his/her designee, is administratively responsible for creating and maintaining a file on each denial of CHS.

The appeal file shall contain: all denial letters, all briefing memorandums prepared in connection with any recommendation to the SUD or Area Director regarding such denial; all correspondence to IHS from claimant or claimant's representative; any other relevant correspondence, maps, bills, or receipts; records of telephone calls to or from claimant or claimant's representative; correspondence relative to any inquiry (i.e., congressional, State official, etc.) made on behalf of the claimant; and pertinent correspondence relative to prior appeal by the same claimant.

Tribal organizations that operate a facility and/or CHS programs pursuant to P.L. 93-638, as amended, and such contract includes carrying out the supervisory and administrative duties of the SUD, the designated tribal official shall have the same duties and responsibilities as the SUD.

Area Directors, or their designees, are responsible for: (a) establishing individual alphabetical patient appeals files that contain all documentation in chronological order for all appeals, and (b) for forwarding copies of appeals files to Headquarters upon request.

Area Director, or their designees, should not routinely forward informational copies of all denials to the Headquarters CHS office.

The Headquarters CHS office is the focal point for processing all CHS appeals to the Director, IHS. All appeal files received by IHS Headquarters are screened in the CHS office to ensure that all required correspondence is included in chronological order.

The Principal CHS Consultant, Headquarters, or his/her representative, analyzes the issues contained in the appeal and processes the appeal to the extent issues can be handled within established policy.

Each appeal record/file will be maintained for a period of 6 years and 3 months after the IHS CHS appeals process has been exhausted. This time period will allow sufficient time should the patient utilize the civil court process.

Appeals that involve questions of medical judgment, are referred to a physician in the Office of Public Health for review.

Appeals that involve questions that may require a legal opinion are reviewed by staff in the Division of Regulatory and Legal Affairs (DRLA), Office of Management Support, prior to being forwarded to the OGC by the DRLA.

The decision of the Director, IHS, shall constitute final administrative action.

The IHS/Executive Secretariat will fax incoming controlled correspondence to the appropriate Area(s). Each CHS officer will analyze the correspondence and submit all necessary documentation to Headquarters so that the CHS Branch, Headquarters, will be able to prepare a response. If there were no appeals to the Area Office or SUD, the CHS Branch is to be so notified. Copies of all determinations issued within the Area are to be submitted to the CHS Branch. If an appeal(s) was submitted to either the SUD or Area Director and the SUD or Area Director has not issued a determination, a status report is to be submitted to support the actions that have been taken.

The CHS Commitment Registers will be maintained at each authorizing location.  The CHS Commitment Register must contain the following minimum information:

Date of Authorization

Authorization Number

Provider Name

Patient Name

Date of Service

Allowance Amount

Estimated Cost of Service

Balance of Funds

Exhibit 2-3-E provides the recommended format for a Commitment Register that meets the above minimum requirements.

The Commitment Register 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 SUD/Tribal Health Director and the Clinical Director/CHS Committee at least-once a month.

An entry will be made on the Commitment Register for each obligation of funds, or modification of obligation of funds.  The entries will be made daily to reflect the services authorized that working day.  Entries should not be delayed beyond 3 working days from the date of referral or notification of services provided.

Each SU will establish a followup system for all authorizations that have not been completed and returned within 90 days of issuance.  Exhibit 2-3-D is a recommended form letter for use in these followups.

 

The CHS Commitment Register (CHS/MIS) will be reconciled with the official Financial Management Report, SHR 424, each month of the fiscal year.  The recommended procedures for reconciliation of the Commitment Register are provided in Exhibit 2-3-F.

 

The appropriate workload and fiscal codes will be entered into the data system, as specified in the Federal Register , Vo. 55, No. 152, Core Data Set Requirements (CDSR).

 

Background.

The fiscal year (FY) 1987 Appropriation Act for the IHS, P.L. 99-591, established the CHEF solely for the purpose of meeting the extraordinary medical costs associated with the treatment of victims of disasters or catastrophic illness who are within the responsibility of IHS.

The FY 1987 act appropriated $10 million.  The Act directed that the CHEF shall not be allocated, apportioned, or delegated on a SU, Area Office, or any other basis.  In FY 1990, as authorized by P.L. 100-713, the amendments to P.L. 94-437 (November 23, 1988), the Congress increased the CHEF appropriation to $12 million.  Effective FY 1993, the Federal Medical Care Recovery Act (FMCRA) funds were returned directly to the SUs, pursuant to Section 207 of the Amendments to the Indian Health Care Improvement Act and are no longer added to the CHEF as they were in the past.

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 some mental disorders are examples of conditions that frequently require multiple or prolonged hospital stays and extensive treatment after discharge.

Public Law 100-713 authorized the CHEF as a new program and required the IHS to publish regulations governing the program.  Further amendments to P.L. 94-437 (P.L. 102-573, October 29, 1992), changed the calculation and level of the CHEF threshold.  While regulations are being developed, Headquarters CHEF guidelines serve as interim policy governing the CHEF program.

General Policy.

The resources of CHEF will be expended according to the basic requirements of the CHS program, and will be made available to partially reimburse for expenditures on patient who incur extraordinary medical costs.

Obligations against the CHEF in excess of $50,000 will be made only in cases where local management documents that it would be medically and fiscally inappropriate to transfer the patient to an IHS, tribal, or less costly contract provider.

Requirements for alternate resources shall be met before reimbursement can be expected 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 shall be returned to the Headquarters CHEF account.  For specific details on the CHEF, reference the most recent CHEF guidelines.

Cost Threshold

The CHEF threshold is adjusted according to CHEF experience, within the range established by law.  Language in P.L. 102-573 requires that the Secretary shall establish the threshold cost at not less than $15,000 or not more than $25,000 for 1993.  The threshold for subsequent years is based on the percentage increase of the expenditures for all urban consumers.

The cost threshold includes only those costs remaining after payment has been made by Federal, State, Local, private health insurance, or other applicable alternate resources.

Purpose  The purpose of the Fiscal Intermediary (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 to provide statistical and financial reports to the IHS in administration of its CHS program.  The FI pays the following object class codes:

Patient and Escort Travel:  Includes travel and related costs, e.g., lodging, meals, etc.

Medical Lab Services-Outpatient Non-IHS:  Includes laboratory costs for outpatients at contract facilities.  If pathologists and lab fees are invoiced together use 25.2A.  Excludes pathologist professional fee invoiced separately (use 25.4D).

Medical Lab Services-Inpatient and Outpatient Facility:  Includes all laboratory costs for inpatients and outpatient at IHS facilities referred to contract facilities.  Excludes pathologist professional fee invoiced separately (use 25.4C).

Dental Laboratory - Includes dental prosthetic fabrication services provided by dental laboratories.  Excludes any dentist professional fee (see 25.4E).

Non-Federal Hospitalization - Includes inpatient services in non-Federal hospitals.

X-ray services-Outpatient Non-IHS:  Includes X-ray services for outpatients at contract facilities.  If radiologist and facility fees are invoiced together, use 25.2H.  Excludes radiologist professional fee invoiced separately (use 25.4D).

X-ray Services-Inpatient and Outpatient IHS:  Includes all radiology costs for inpatients and outpatients at IHS facilities referred to contract facilities.  Excludes radiologist professional fee invoiced separately (use 25.4C).

Hospital Outpatient - Includes ambulatory services at contract hospitals other than emergency room services.  Excludes any physician professional fee billed separately.  (See 25.4D)

Emergency Room (ER) Services - Includes non-IHS hospital ER services.  Includes any ER physician fees whether combined or billed separately.

Dialysis - Contract Hospital Inpatient Services. (FY 1991 and prior FYs only.)

Physical Therapy Services:  Includes all contract therapy services invoiced separately.  Excludes all physician professional fees (use 25,4D.)

Physician-Inpatient-IHS Facility:  Includes contract physician services for patients hospitalized in IHS facilities.  Includes radiologist and pathologist professional fees invoiced separately.

Physician Inpatient - Non IHS facility - Includes all physician services for patients hospitalized in non-IHS facilities.

Physician-Outpatient-IHS-Facility:  Includes all contract physician services for outpatients in IHS facilities.  Includes radiologist and pathologist professional fees invoiced separately.

Physician Outpatient - Non-IHS Facility - Includes all physician services for outpatients in non-IHS facilities and physician offices.

Dentists - Includes all services provided by dentists to inpatients and outpatients.  Includes combined dental laboratory costs and dental services.

Fee Basis Specialist-IHS Facility:  Includes all consultant services other than physicians.  Examples are nurse anesthetists, audiologists, speech therapists, podiatrists, and dental hygienists (cost centers 268 and 368).

Fee Basis Specialist-Non-IHS Facility:  Includes all consultant services in non-IHS facilities other than physicians.  Examples are:  Nurse anesthetists, audiologists, dental hygienists, and podiatrists.

Refractions - IHS/Non-IHS Facility - Eye and vision exams only, not for injuries or other medical reasons, by ophthalmologists and optometrists.

Extended Care Facilities:  Includes rehabilitation, skilled nursing facilities, psychiatric inpatient facilities, and psychiatric inpatient care in an acute facility exceeding 30 days.  Excludes any physician fee (use 25.4B).

Dialysis - Physician Outpatient and Inpatient services in IHS; or

Non-IHS Facility.  (FY 1991 and prior FYs only.)

Consumable Medical and Surgical Supplies:  Includes medical, dental, and surgical supplies.  Examples are dressings, bandages, and catheters.

Non-consumable Medical and Surgical Supplies:  Includes rental and purchase of Wheelchairs, apnea monitors, oxygen tanks, beds, etc.

Eyeglasses:  Includes eyeglasses and repair to eyeglasses.  If eyeglasses are billed with the professional fee use 26.3K.

Hearing Aids:  Includes costs of hearing aid devices and repairs to hearing aids.

Interest

Authority

The authority for 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 functions 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 or 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."

FI Operations

For FI operations information refer to "FI Reference Manual" for IHS/CHS, dated September, 1995.  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 mandated to protect patients' medical information from all security risks.  Changes to the FI data system allowing access to data and the ability to communicate through local area networks shall include provisions to ensure patient confidentiality.  Ensuring compliance with the Privacy Act 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 the business of patient care as defined in the IHS mission statement.  The following steps provide necessary guidance in accessing the FI data system:

Access to FI data is accomplished through computer log-on to the IHS Intranet at Headquarters West in Albuquerque, New Mexico.

The staff involved with the Intranet at Headquarters West and the data system at New Mexico Blue Cross Blue Shield (NMBCBS) are responsible for ensuring that the systems are secure.  Firewalls at each location guard against unauthorized access.

Procedures must be developed and implements at each IHS site to ensure that Intranet access to the FI data system is revoked when employees leave CHS employment.  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.

The FI staff members are required to sign a code of conduct documenting their responsibility to adhere to the Privacy Act.

The FI violators of the code of conduct will be terminated from employment.

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.

Training will be provided by IHS and FI staff via teleconferencing for new users.  Training will also be provided to current staff as changes and enhancements occur.

Problems or incidents must be reported to the Area CHSO.

Procedures.  In order for access to the FI data system to be granted, the following procedures must be followed:

Requests.  Area CHSOs should submit the form found in Manual Exhibit 2-3-J to the FI Project Officer.  The CHSO must verify that a confidentiality statement is on file and that privacy act training/orientation has been given to each CHS employee before access to the FI data system is granted.

Approval.  Only the FI Project Officer may approve or deny the requests for CHS data access.  When requests are denied, the reasons are documented and returned to the Area CHSO.  Copies of the approved requests will be returned to the respective Area and copies faxed to the FI.

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 FI Project Officer designated by the IHS as requested.

Other Reports.  The FI staff will provide reports to the FI Project Officer as requested.  These reports include information about the types of information accessed (i.e.., providers) and how often the information is requested.

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-A.

Dental Priorities.

See Manual Exhibit 2-3-B.

Guidelines for recording and reporting on deferred services are:

 

Cases reported as deferred services 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 SU has the option to pay for care deferred in a prior FY.

The service deferred must be elective (i.e., "deferrable"(, not emergent/urgent.  Denials for payment of care received that were not within medical priorities are reported through the denial reporting process, not as a deferrable service.

The service required cannot be accessible/available to the patient in the IHS direct system (care provided directly in IHS clinics or facilities, not CHS care) within the usual and customary treatment and referral patterns.

The service deferred must be within IHS medical priorities.  Items listed in the IHS medical priorities as procedures that IHS will not pay for cannot be reported as a deferrable service.

The reporting formats and guidelines for deferred services accrued and deferred services expenditures are sent to the Areas on an annual basis.

All SUs will maintain the following elements to review and monitor the referral and expenditure of CHS funds.

 

There shall be an active CHS Committee to review CHS referrals and emergency cases.  Membership should include, at a minimum, the Clinical Director, Director of Nurses or Clinical Manager (or other primary care provider), Utilization Review Nurse (if stated), Administrative Officer, and the CHS Specialist.  Meetings must be held at least once a week to determine the appropriateness of referral requests for expenditure of CHS funds.

Committee members who are related to patients, for whom an inquiry is being made, must excuse themselves from case discussion and decisions.  The record of the meeting must reflect the reason that the employee excused himself/herself from the case.  The employee with procurement authority must not sign the purchase/delivery order for patients to whom she/he is related.

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 service must not be available in an IHS/tribal facility.

The patient must be CHS eligible.

The referral shall be made to the appropriate provider based on cost/quality factors, or an exception justified.

For review of emergency cases, the care provided shall be verified as an emergency situation.

Care must not be deferred for cases where full reimbursement is available.

The minutes of each Committee meeting will be maintained to accurately reflect the determination of each case.

The Committee 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.

The amendment of the Indian Health Care Improvement Act, Section 220 of P.L. 102-573, directs the CHS program to issue a purchase  order or a denial within five days of notification of a claim.

Section 220 states - -

 

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 accordance with subsection (1), 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.  If a patient is potentially eligible for an alternate resource, issue a denial and advise the patient in the application process.