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- Notice of Privacy Practice – Health Clinic
The NHBP Health Department provides two types of health services: “Direct Care” and “Contract Health Services” (CHS). These two types of services each have their own set of rules and guidelines.
Office Hours: Mon – Fri 8:30am – 5:00pm
Office Telephone – 269-729-4422 ext 8349
Toll Free – 888-729-4422 ext 8349
Direct Line 269-704-8349
Direct FAX – Fax 269-729-4460
EMERGENCY # – 9 1 1
1. What is Direct Care?
2. What is Contract Health Services?
3. What are Alternate Resources?
4. How can I get Contract Health Service to pay for my medical care?
5. Am I eligible for Contract Health Services?
6. How do I register with CHS?
7. When do I need to notify CHS of my appointment?
8. What services are within Medical Priorities?
9. I received a denial saying Contract Health Service will not authorize payment, why?
10. The Health Department provider gave me a referral. Why is CHS denying the authorization of payment?
11. I received a referral and purchase order (prior authorization) why do I continue to get billing statements in the mail?
12. Who do I contact with questions about CHS?
13. What is the NHBP Contract Health Service Delivery Area?
What is Direct Care?
Direct Care is services provided at the NHBP Health Department. Examples of direct care include primary care, dental care, nutrition counseling, behavioral health services, health education, community nursing services, home visits and more. See the Health Department’s brochure for a full listing of services provided at the NHBP Health Department.
What is Contract Health Services?
The Contract Health Services (CHS) program is funded annually by funds the Tribe receives under its Contract with the Indian Health Services (IHS). It is not an Entitlement Program nor is it an Insurance program.
CHS funds are intended to help pay for care or services to eligible American Indians and Alaska Natives (AI/AN) when no other sources of health care payments are available, or after all other alternate resources have been exhausted.
What are Alternate Resources?
IHS facilities are considered a resource, so CHS funds may not be used for services that are accessible and available at the NHBP Health Department or other IHS facilities. As a general rule, when any IHS facility is within 45 minutes from your home we consider it a resource.
The IHS is considered the payor of last resort. As such, the Indian Health Care Improvement Act requires the NHBP Health Department to establish a procedure to ensure that CHS does not pay for medical care or services if they could have been received at an IHS facility or if other Federal, State, or private sources of reimbursement are available, such as Medicare or Medicaid.
The Health Department requires that all individuals registering with CHS apply for and use any and all alternate resources that are available and accessible. If you have or could have the following, you must exhaust those resources first:
• Medicare A and B,
• State Medicaid,
• State or other federal health program,
• Private insurance, etc.
How can I get Contract Health Service to pay for my medical care?
The CHS Program is not an Entitlement Program or an Insurance Program. The following must occur for CHS to consider authorizing payment for medical care or services:
1. You must be eligible and registered with CHS
2. You must exhaust all possible alternate resources
3. You must meet notification requirements to CHS
4. The Medical care/services you need must be within established NHBP CHS medical priorities.
5. CHS funding must be is available
Am I Eligible for Contract Health Services? [Eligibility]
To be eligible for CHS you will need to meet the eligibility requirements:
1. Be a member of the Nottawaseppi Huron Band of the Potawatomi; or
* A descendent of an enrolled member under the age of 19; or
* A non-Indian woman pregnant with an eligible Indian’s child for the duration of her pregnancy through post-partum (usually 6 weeks); or
* A non-Indian member of an eligible Indian’s household and the medical officer in charge believes services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.
2. Reside in NHBP’s Tribal Contract Health Service Delivery Area (CHSDA): Allegan, Barry, Branch, Calhoun, Kalamazoo, Kent and Ottawa of Michigan. Exceptions apply for individuals temporarily absent from his/her CHSDA. Contact the CHS Specialist for additional information.
3. Have applied for and/or used all alternate resources that are available and accessible to you. The NHBP Health Department is also considered a resource and therefore CHS funds will not be expended for services reasonably accessible and available at the Department.
Eligible patients must register with CHS. If you are eligible, the CHS Specialist requires certain documentation from you. This information must be updated at least annually to confirm your continued eligibility for CHS services. The CHS Specialist will contact you when it is time for you to update your file.
How do I register with CHS? [Registration]
To register with CHS, the following documents must be submitted to CHS:
1. Completed CHS Client Intake Packet which includes the Registration form and Health Services Agreement (can be picked up at any Health Department facility)
2. Social Security Card
3. Proof of being an enrolled member or non-enrolled minor descendent of a member such as a Tribal Identification Card, enrollment papers, or birth certificate.
4. Proof of residency: Driver’s license or state identification card; and acceptable documentation of the your address such as a Rent Agreement or Utility bill; or a notarized letter
5. Alternate Resource Information such as a private insurance card; Medicare card (Part A, B, D or Supplemental); or a Medicaid determination letter (stating that you are ineligible).
When do I need to notify CHS of my appointment? [Notification Requirements]
Notification requirements must be met before an authorization of payment for medical care or services will be considered by CHS.
• Patients seeking CHS authorization for medical care or services that take place outside of the NHBP Health Department are responsible for ensuring that, prior to the provision of medical care and services, CHS is notified of the need for services and supplied with adequate information/documentation to determine the relative medical need for the services (medical necessity) and the individual’s eligibility. The requirement for notice prior to providing medical care and services may be waived by CHS if the Managed Care Work-Group determines that giving notice prior to obtaining the medical services was impracticable or other good cause exists for failure to comply.
• An individual or agency acting on behalf of the patient, or the patient’s provider will have up to 72 hours after the start of the emergency or admission to notify CHS of the emergency treatment.
• Elderly (55 and older) and disabled have up to 30 days to notify CHS of emergency medical care or services received.
• CHS must be provided with adequate information to be able to determine the relative medical need for the services.
• The 72 hour period may be extended if the Managed Care Work Group determines that notification within the prescribed period was impracticable or that other good cause exists for the failure to comply.
What services are within Medical Priorities? [Medical Priorities]
The NHBP Contract Health Services has established medical priorities. Medical care or services within these medical priorities may be covered by CHS if all eligibility and notification requirements have been met.
The NHBP CHS program currently covers health care services within Priority 1 Medical Priorities: Emergent/Acutely Urgent Care Services:
Priority IA: Diagnostic or therapeutic services that are necessary to prevent the immediate death or serious impairment of the health of the individual; Immediate life-threatening situations; Danger of loss of limb or senses; Unstable condition requiring treatment for stabilization.
Priority IB: Diagnosis and treatment of injuries or medical conditions that, if left untreated, would result in uncertain but potentially grave outcomes; Potential for becoming life threatening; Not immediate emergency; Essential for daily function; No acceptable alternative.
Examples of Priority 1 Medical Priorities:
I received a denial saying Contract Health Service will not authorize payment, why?
If a person is denied Contract Health Services both the patient and provider will be notified in writing of the reason of denial. A denial may be issued for the following reasons:
1. Eligibility Not Established
2. Alternate Resources Available
3. No Notification of Emergency Service With-In 72 Hours
4. Insufficient Medical Information (emergency room notes not sent)
5. NHBP Health Department Was Available to Provide Care
6. Care Not Within Medical Priority
7. Lack of Funds
8. Lives Outside Of the Contract Health Service Delivery Area
9. No Prior Notification for non-emergent care
10. No Notification of Emergency Service With-in 30 days for Elderly or Disabled
The Health Department provider gave me a referral. Why is CHS denying the authorization of payment?
A provider’s referral is not a guarantee of payment for any services. Some Contract Health Service referral’s are not within established and funded medical priorities. Therefore some referrals cannot be paid with Contract Health Service funds.
I received a referral and purchase order (prior authorization) why do I continue to get billing statements in the mail?
If you received a referral and prior authorization and you continue to get billing statements something could be wrong. Once the provider returns the purchase order and the billing statement, payment is made. You should bring the statement into CHS for a review.
Who do I contact with questions about NHBP CHS?
What is the NHBP Contract Health Service Delivery Area?
The NHBP’s Tribal Contract Health Service Delivery Area (CHSDA) is composed of the following counties of Michigan:
Contract Health Specialist