Ysleta del Sur Pueblo
Health
YSLETA
Pueblo
Community
Wellness
Patients
Care
Traditions
9313 Juanchido
Ysleta del Sur Pueblo, TX 79907
Office: 915-858-2117
After hours cell: 915-276-4247
Fax No: 915-860-6166
IMPORTANT NOTICE
CONTRACT HEALTH SERVICES IS NOT AN ENTITLEMENT PROGRAM.
CONTRACT HEALTH SERVICES IS NOT AN INSURANCE PLAN.
________________________________________
Ysleta del Sur Pueblo Contract Health Services program is federally
funded by the Indian Health Services, a Federal Agency.
The Department of Health and Human Services of the Ysleta del Sur
Pueblo, a Federally Recognized Indian Tribe, Administers the IHS program
for its enrolled tribal members residing in El Paso and Hudspeth
Counties, Texas.
Pursuant to stringent legal requirements and under strict limitations, the
Contract Health Services Program helps pay the costs of Non-YDSP
(“Outside”) healthcare received by tribal members.
Payment for “outside” health care services is contingent upon the
availability of federally appropriated funds.
________________________________________
CONTRACT HEALTH SERVICES IS NOT A HEALTH SERVICE PAYMENT GUARANTEE.
CONTRACT HEALTH SERVICES IS THE PAYOR OF LAST RESORT.
IMPORTANT NOTICE
YSLETA DEL SUR PUEBLO
CONTRACT HEALTH GUIDELINES
TABLE OF CONTENTS
SECTION TITLE
Page #
1
1
Welcome to Contract Health Services
The Purpose of CHC
The Purpose of these Guidelines
Federal Funding and Priority Status of Medical Needs
Medical Authority
2
Eligible Individuals
3
Service Area Population
Individual Eligibility
Proof of Residency in El Paso or Hudspeth Counties
Medical Cards
3
Mandatory Use of YDSP Services
5
YDSP Services
Primary Care
Dental Office
Optometry Office
Other YDSP Programs
Supplies
4
Authorization of Health Care Services
8
Non-Emergency Services Including Referrals
What is an Emergency
Emergency Authorization
Emergency Care Providers
Emergency Transport and Services
Urgent Care Authorization
5
Medically Necessary & Reasonable Cost
Family Planning
Obstetric Service Requirements
Pharmaceuticals
Alternative Resources
ii
10
6
ALTERNATE RESOURCES
12
Types of Alternative Resources
Refusal to Obtain or Use Alternative Resources
Assistance in Obtaining Alternative Resources
7
Denials and Appeals
13
Reasons for Denials
Reconsideration and Appeals
15
Annex A
Priority Status of Medical Needs
Priority 1
Priority 2
Priority 3
ii
SECTION 1: WELCOME TO CONTRACT HEALTH SERVICES
Ysleta del Sur Pueblo (YDSP), through various programs of its
Department of Health and Human Services (HHS), strives to ensure
comprehensive health care for its Tribal Members. YDSP health care
programs include among others the Alcohol and Substance Abuse
Program (ASAP); the Social Services Program (SSP); the Primary
Care Physician Program (PCP); and the Contract Health Services
Program (CHS). These guidelines provide information to Tribal
Members on the CHS program. YDSP Tribal Council retains the
right to modify these Guidelines in accord with federal law and
regulations to the extent such modifications do not impinge upon the quality of services
delivered.
THE PURPOSE OF CHS
Contract Health Services is a program of Indian Health Services (IHS), an agency within the
United States Department of Health and Human Services. YDSP, through its HHS, administers
the CHS program on its federal Indian reservation. Unlike other YDSP health care programs,
CHS does not deliver health care services; instead, it is a payment mechanism for certain health
care costs incurred by Tribal Members.
YDSP health care programs offer their services through YDSP providers, such as the YDSP
dentist or the optometrist, at YDSP health care facilities like the Community Health Center
(CHC) or even in homes. But sometimes the Tribal Member must seek health care services
elsewhere from someone else. We call this Outside health care.
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Pursuant to stringent legal requirements and under strict limitations CHS helps pay the cost of
Outside health care received by a Tribal Member but only if –
 the Tribal Member meets eligibility requirements;
 the Tribal Member could not have reasonably received the same health care services
from a YDSP provider or facility;
 the CHS had authorized the treatment and approved the Outside provider or facility;
 the health care services were medically necessary;
 the costs of the health care services are reasonable;
 all alternate resources have been sought and exhausted;
 federal funds are available for payment; and,
 the Tribal Member followed proper protocol in requesting CHS aid.
Each one of the listed requirements or limitations is explained in these Guidelines.
It is important that Tribal Members and their Outside health care providers understand that CHS
is the Payor of Last Resort. CHS will not pay unless there is no other money or method to take
care of the cost of the Outside health care services. CHS is not a government entitlement; it is not
an insurance policy; and it is not a third-party beneficiary payment guarantee. CHS is a very
limited and restricted fund used to pay certain health care costs, and YDSP expects both Tribal
Members and health care providers act in a reasonable fashion to conserve the fund to the
greatest extent possible.
THE PURPOSE OF THESE GUIDELINES
It goes without saying that individuals capable of making reasonable decisions are primarily
responsible for their own health and well-being. Individuals fulfill that responsibility by learning
about and living healthy lifestyles, acquiring health insurance and other alternate resources if
reasonably available, taking advantage of preventive care, and seeking appropriate health care
services when necessary. These Guidelines leave that primary responsibility with each
individual. The particular goals of the Guidelines are as follow:
2





To provide information to Tribal Members about the CHS
Program;
To provide guidance for the effective and efficient
management of the Program;
To ensure coordination of CHS benefits with those of other
YDSP programs and alternate resources;
To define and delegate to the CHS Committee and the YDSP
Medical Director, to the greatest extent possible, authority and
discretion to operate the CHS program; and,
To ensure compliance with applicable federal law and
regulations
FEDERAL FUNDING AND PRIORITY STATUS OF MEDICAL NEEDS
The source of payments under the CHS Program is limited to federally-appropriated funds – the
amount of money which Congress has made available to pay covered services. It is an
unfortunate fact that Congress rarely provides enough money to pay all health care costs covered
by the CHS Program. When federal funds are insufficient, YDSP will prioritize the expenditure
of the money on the basis of relative medical needs. Annex A is the YDSP’s schedule of Priority
Status of Medical Needs.
MEDICAL AUTHORITY
The CHS Committee is the designated on-site medical authority for administration of the CHS
Program. The CHS Committee approves provider contracts and determines the current Priority
Status of Medical Needs, the medical necessity and reasonable cost of health care services,
requests for referral, and eligibility issues. The CHS Committee makes its decisions based on
these Guidelines and the Priority Status of Medical Needs. The YDSP Medical Director
exercises day to day oversight of CHS operations and, where authorized by the Committee,
makes eligibility and medical necessity determinations in exigent circumstances.
SECTION 2: ELIGIBLE INDVIDUALS
SERVICE AREA AND POPULATION
The CHS Program’s service area is El Paso and Hudspeth Counties of Texas. The CHS’s service
population is members in good standing with YDSP and a few non-Indian individuals as
specifically provided in 45 C.F.R. § 136.12. Unless the context indicates otherwise, the term
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“Tribal Member” will include the other non-Indian individuals throughout these Guidelines.
INDIVIDUAL ELIGIBILITY
To the extent that resources permit, and subject to the
provisions of these Guidelines, CHS funds will be
made available to the following individuals:
 Tribal Members in good standing with YDSP
who reside in El Paso or Hudspeth Counties,
and who maintain their current annual status
with YDSP Census and CHS.
 Non-Indian female residing in El Paso or
Hudspeth County and who is pregnant with the
child of Tribal Member in good standing with
YDSP regardless of the Member’s residence.
The Tribal Member must sign an Acknowledgment of Paternity Statement with the CHC
Medical Records Technician. Eligible care shall extend from the first prenatal visit
through the first post-partum visit, as well as any fees relating directly to complications
from the pregnancy and delivery. Notification of the pregnancy must be given to the
CHS Program by the end of the second trimester (the end of the 25th week).
 Non-Indian spouses and non-Indian dependent members of an eligible Tribal Member’s
immediate family for the treatment of acute infectious diseases or other conditions which
constitute public health hazards such as flu season outbreaks.
 Transient individuals (persons who are in travel or are temporarily employed, such as
seasonal or migratory workers) who would be eligible for contract health services at the
place of their permanent residence but are temporarily absent from their residences.
 Students who would be eligible for contract health services at the place of their
permanent residence but are absent during their full-time attendance at programs of
vocational, technical, or academic education, including normal school breaks (such as
vacations, semester or other scheduled breaks occurring during their attendance) and for a
period not to exceed 180 days after the completion of the course of study. CHS shall rely
upon the determination of full time status by the registrar of a student’s school.
 Tribal Members leaving the El Paso and Hudspeth Counties may continue receiving
services for 180 days. Upon leaving the service area, the Tribal Member must notify the
CHS Program of the departure in writing. Failure to notify CHS will result in a denial of
request for payment. Eligibility will terminate after the 180-day period. 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 that
occur after 180 days.
 Minor Tribal Members who are placed and remain in foster care outside El Paso and
Hudspeth Counties by order of a court of competent jurisdiction and who were eligible
for CHS at the time of the court order.
 Tribal Members who would be eligible for contract health services at the place of their
permanent residence but are temporarily absent from their residences while traveling
throughout the United States or travelling to foreign countries other than to Ciudad Juarez
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in Mexico, but only to the extent of 50% of the reasonable cost of medically necessary
services not covered by alternate resources, or 100% in case of an accidental injury or
medical emergency.
PROOF OF RESIDENCY IN EL PASO OR HUDSPETH COUNTIES
To access the CHS Program, a Tribal Member must on an annual basis
register with Patient Registration in the CHC. The Tribal Member
must present a current Tribal Census Card. The person must also
substantiate proof of residency in the service area. The following
types of proof are acceptable:
 A non-expired government issued photo I.D. with Tribal
Member’s current home address, such as a Texas driver’s
license, or
 Any two of the following documents – recent mail
addressed to Tribal Member, current voter’s registration card,
latest property tax, mortgage, or utility payment receipt; and
 A notarized letter and social worker visit as deemed
necessary by the CHS Committee.
MEDICAL CARDS
CHS shall issue annual Medical Cards to eligible individuals upon initial registration and annual
updates of status. A Tribal Member moving into the service area will not be eligible for CHS
benefits until six months after registering, at which time a Medical Card will be issued.
Current status is maintained by filing with the HHS Medical Records office the following
information:
 Proof of residency
 Copy of social security card for initial registration
 Copy of current Census Card and CHS Medical Card
 Copies of alternate resource cards front and back (e.g. Medicare card, VA ID card,
insurance card)
Medical Cards must be provided to Outside providers and facilities before services are rendered
or a soon as possible thereafter in order for costs to be covered.
SECTION 3: MANDATORY USE OF YDSP SERVICES
CHS funds shall not be expended for health care services that are available and reasonably
accessible at YDSP health care facilities. Tribal Members, regardless of alternate resources, may
receive health care services at a YDSP health care facility as well as referrals needed for
5
specialty care. CHS will bill all alternate resources for services provided by YDSP, but Tribal
Members with private insurance will not be responsible for co-pays, deductibles, or any other
cost for which the Tribal Member would normally have to pay under the private insurance
policy.
YDSP SERVICES
Tribal Members need to know what services are available through YDSP providers and health
care facilities before arranging for health care services elsewhere. A general description of
available services follows, but Tribal Members should always confirm with CHS whether YDSP
services are available. Types of services at YDSP health care facilities include but are not limited
to the following:
 Primary care
 Dental Services
 Optometry Services
 Social Services
 Mental Health Services
 Community Health Services
 Alcohol and Substance Abuse
PRIMARY CARE
YDSP operates a Primary Care Physician Program. The
YDSP health care service providers serve as Primary Care
Physicians for all Tribal Members. Primary care includes
but is not limited to the following services:
 Medical Services of a general practice nature;
 School physicals (the ability to perform work
physicals are limited; employer forms can be faxed
or emailed to CHS for review by the YDSP Medical
Director to determine if YDSP providers can
accommodate the request. Due to the detail in some work physicals, YDSP providers
may refer tribal member may to Outside resources)
 Preventive Care
Primary Care encompasses a wide range of preventive care. CHS resources are limited and
compliance with YDSP preventive care requirements reduces the need for future health care
services. Preventive care includes:
 Immunizations;
 Attending all primary care appointments;
 Pap smears by YDSP providers;
 All medical exams at HCH with annual lab panel;
 Dental cleaning and visits every six months unless the doctor advises otherwise;
 Optometry vision screening once a year unless the doctor advises otherwise;
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 Diabetics shall participate in the Diabetic Education and Support program
 Such other actions prescribed by YDSP providers
YDSP providers may modify these preventive care requirements and make such others for each
individual as deemed best by the provider. Compliance with preventive care requirements,
including missed appointments, will be considered by YDSP Medical Director and CHS
Committee in determining whether any medically necessary service could have been avoided and
thus represents an unreasonable cost.
DENTAL OFFICE
Services include education, preventive care, general dentistry, as well referrals but only as
deemed necessary by the Dentist and approved by the YDSP Medical Director and CHS
Committee. When recommending a referral, the Dental Office will present details to the CHS
Committee regarding the individual’s preventive appointments and compliance with requests
previously made by the Dentist.
OPTOMETRY OFFICE
Services include regular eye examinations, education, and general optometry practice. as well
referrals but only as deemed necessary by the Optometrist and approved by the YDSP Medical
Director and CHS Committee. When recommending a referral, the Optometry Office will present
details to the CHS Committee regarding the individual’s preventive appointments and
compliance with requests previously made by the Optometrist.
OTHER YDSP PROGRAMS
YDSP offers other health care programs which can provide much needed health care services or
referrals for such services to Tribal Members. Before such services are offered, the client is first
screened to determine if treatment is necessary. Details can be obtained from the different
programs.
SUPPLIES
YDSP will be responsible for providing all supplies for outpatient homehealth care services as prescribed by a medical physician, YDSP or
otherwise, including oxygen tanks.
YDSP provides free Glucometers and strips to diabetic Tribal Members at
their monthly diabetes education meeting.
CHS can assist with the purchase of eyeglasses once a year depending on
the Priority Status of Medical Needs. The purchase of eyeglasses more than
once a year will be considered by the YDSP Medical Director and CHS
7
Committee on a case-by-case basis. Contact lenses, however, cannot be purchased through CHS
unless the patient has Keratoconus or high Anisometropia without Amblyopia.
SECTION 4: AUTHORIZATION OF HEALTH CARE SERVICES
Under normal circumstances, no CHS payments will be authorized for health care services
obtained from Outside providers or in Outside facilities unless
(1) CHS previously issued a purchase order authorizing the
treatment (2) to an approved Outside medical care provider.
CHS maintains a list of approved Outside providers and
facilities. They are referred to as in-network providers. No
CHS payments will be made to out-of-network providers
unless, for good cause shown, the CHS Committee waives this
restriction. CHS can assist a Tribal Member in finding a
suitable provider.
Normal authorization protocol differs in emergency and urgent
care situations.
NON-EMERGENCY SERVICES INCLUDING REFERRALS
Approval of all non-emergency and all non-urgent medical care services begins with a visit to
the CHC prior to the rendition of any services in order to obtain a purchase order. The Tribal
Member shall notify CHS of the need for the services and supply information that CHS deems
necessary to determine the medical necessity for services and the Tribal Member’s eligibility.
The Tribal Member may be referred to a YDSP provider for a recommendation.
Requests for referrals, whether made by YDSP or Outside providers, also require the issuance of
a purchase order prior to the rendition of any services. The Tribal Member or the providers shall
notify CHS of the need for the services and supply information that CHS deems necessary to
determine the medical necessity for services. Referrals shall only be made to physicians be on
the approved provider list.
If the treatment is authorized, CHS will issue the purchase order and schedule appointments
with the providers. Tribal member must communicate any rescheduled of appointments to CHS
to avoid a denial.
WHAT IS AN EMERGENCY?
Emergency means any medical condition for which immediate medical attention is necessary to
prevent the death or serious impairment of the health of an individual.
Emergency care is extremely costly and should only be used for real emergencies, not for
primary or urgent care. Just because a Tribal Member received treatment in an emergency room
does not mean that it was an emergency situation. If the medical care was not necessary to
8
prevent the person’s death or serious impairment of health, it was not an emergency and a
request for CHS assistance will be denied.
EMERGENCY AUTHORIZATION
In emergency cases, the Tribal Member, or an individual or agency acting on behalf of the Tribal
Member, or the health care provider shall within 72 hours after the beginning of treatment for the
condition or after admission to a health care facility notify the YDSP Medical Director of the fact
of the admission or treatment, and supply information that the YDSP Medical Director deems
necessary to determine the medical necessity for the services and the eligibility of the Tribal
Member for the services. The 72-hour period may be extended if the YDSP Medical Director
determines that notification within the prescribed period was impracticable or that other good
cause exists for the failure to comply.
Elderly and disabled individuals have 30 days to notify the YDSP Medical Director of
emergency health care services received from Outside medical providers or at Outside medical
facilities. An elderly individual is one who is 65 years of age or older. A disabled individual is
one who has a physical or mental condition that reasonably prevents the person from providing
or cooperating in obtaining the information necessary to notify the YDSP Medical Director of
the person’s receipt of emergency care from an Outside provider or facility within 72 hours after
the
Outside
provider
began
to
deliver
the
care.
EMERGENCY CARE PROVIDERS
Tribal Members with sufficient alternate resources (Medicare, Medicaid, private insurance) can
be directed to the following hospitals:
 University Medical Center
 Del Sol Medical Center
 Sierra Hospital
 Providence Memorial Hospital
 Las Palmas Medical Center
 Foundation Surgical Hospital of El Paso (formerly East El Paso Physicians Medical
Center)
 Sierra Providence East Hospital
Tribal Members lacking sufficient alternate resources shall be directed to University Medical
9
Center where such Tribal Member may be provided charity care based on the Federal Income
Poverty Guidelines issued by the U.S. Department of Health and Human Services as published
annually in the Federal Register. The HHS Medical social Worker will assist the Tribal member
in applying for charity care.
EMERGENCY TRANSPORT AND SERVICES
CHS funds are available for payment for
services where Tribal Member’s condition
dictated immediate transport to the nearest
but non-approved hospital, but only after a
review of the medical record and assessment
of the patient’s situation at the time which
demonstrates a compelling reason to believe
that a true emergency existed.
URGENT CARE AUTHORIZATION
Tribal Members may face acute but non-emergency situations which require immediate
treatment (e.g., a cut requiring stitches, a child with fever over 102 degrees) and YDSP providers
and facilities are not available. Pre-authorization of services is also difficult to obtain in such
circumstances. The most common instance is when CHC is not open, such as after hours and on
weekends. After hours is normally 5:00 p.m. each Monday, Tuesday, Wednesday, and Thursday
until 8:00 a.m. the following morning. Weekends are 5:00 p.m. Friday until 8:00 a.m. Monday.
Tribal Members with urgent care needs must use Urgent Care Health Clinics, not Emergency
Rooms. If the medical care was not necessary to prevent the person’s death or serious
impairment of health, it was not an emergency and a request for CHS assistance will be denied.
The same authorization procedure for emergency care treatment also applies to urgent care
services.
Tribal members with urgent care needs must use an in-network provider or any claim will be
denied. CHS will maintain a list of in-network urgent care providers.
SECTION 5:
MEDICALLY NECESSARY & REASONABLE COST
Payments are limited to the reasonable cost of medically necessary services. “Medically
necessary” means health care services or procedures that a prudent physician would provide to a
patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its
symptoms in a manner that is (a) in accordance with generally accepted standards of medical
practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c)
not primarily for the economic benefit of the health plans and purchasers or for the convenience
of the patient, treating physician, or other health care provider.
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“Reasonable cost” refers to the base amount that is treated as the standard or most common
charge for a particular medical service when rendered in a the geographic area where services
were rendered. Reasonable cost shall not exceed the amount ordinarily charged by most
providers for comparable services and supplies in the area.
Outside health care services are never medically necessary and the costs of such services are
therefor never reasonable where the same services were reasonably accessible to the Tribal
Member by YDSP provider or facility, or if the services were due in whole or in part by the
Tribal Member’s failure to obtain required preventive care which was reasonably accessible to
the Tribal Member by a YDSP provider or health care facility.
In certain instances medically necessary health care services are subject to further restrictions in
addition to reasonable cost. The following services are subject to such restrictions
FAMILY PLANNING
Prevention of pregnancy methods are covered including sterilizations. Reversal of sterilization
methods are not. Only certain abortions are covered and are governed by federal regulations
(detailed information/special conditions are available from the service providers). Elective
abortions are not covered.
OBSTETRIC SERVICE REQUIREMENTS





CHS must be notified of the pregnancy by the end of the second trimester (the end of the
25th week). Failure to notify will result in denial of payment.
Pregnancy must be confirmed by a pregnancy test. Tribal Members without alternate
resources must be tested at a YDSP health care
facility.
Tribal Members with no resources must apply for
Medicaid. An appointment can be facilitated with the
Medical Social Worker at YDSP health care facility to
assist with the application process. A letter of
eligibility/denial from Medicaid must be presented to
CHS within 72 hours (3 days) of reporting pregnancy.
CHS covers two sonograms. Additional sonograms
must be medically necessary and be approved by the
CHS Committee.
CHS requires notification upon delivery of newborn
child.
PHARMACEUTICALS
All prescribed medications must be obtained at approved Walgreens or other CHS designated
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pharmacy.
SECTION 6: ALTERNATE RESOURCES
“Alternate resources” means health care resources other than those of the Indian Health Service.
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 or XIX of the
Social Security Act (i.e., Medicare, Medicaid), State or local health care programs, and private
insurance.
TYPES OF ALTERNATE RESOURCES
Alternate resources may include but are not limited to:
 Medicare
 Medicaid
 Veterans Administration
 William Beaumont Army Medical Center
 University Medical Center
 Other state/federally-funded health programs (for example, CHIP)
 Private Insurance (includes insurance provided by Ysleta Del Sur Pueblo)
 Third Party Liability (i.e. lawsuit settlement of vehicle accident)
REFUSAL TO OBTAIN OR USE ALTERNATE RESOURCES
CHS is always the Payor of Last Resort. CHS payments are made only
when all alternate resources have been exhausted. Failure to exhaust
alternate resources includes the failure to obtain resources for which
the Tribal Member is eligible.
 CHS payment shall be denied if the Tribal Member has failed
to exhaust all alternate resources.
 CHS payment will be denied if there is a lack of documented
efforts or the refusal to apply for alternate resources when
there is a reasonable possibility of availability.
 CHS payment will be denied if an alternate resource program
issues a denial because the applicant failed to supply
information or to complete the application.
 Medicaid and Medicare applicants must provide a copy of the
denial or acceptance letter and notify CHS as soon as coverage
has expired, changed or is terminated
ASSISTANCE IN OBTAINING ALTERNATE RESOURCES
CHS can assist Tribal members in locating and applying for alternate resources. Tribal Members
should be prepared to provide to the Medical Social Worker documents to establish qualification:
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
Income – IRS Form W2; wage and earning statement; pay check remittance; individual
tax return; unemployment insurance; employer statement of applicant’s income on
official company letter head; bank statement or other appropriate indicators of yearly,
monthly, weekly or hourly income;
 Proof of Residency – mail addressed to patient or patient’s spouse or children; driver’s
license; other official identification; school enrollment records; property tax receipts; rent
receipts; mortgage payment receipts and utility receipts;
 Number of family members – Names and ages of immediate family members living in
the household.
After turning in the required documentation, the Medical Social Worker will assist Tribal
Members in completing the appropriate applications.
SECTION 7: DENIALS AND APPEALS
REASONS FOR DENIALS
The CHS Committee may deny payment of services for the following reasons:
 Not a Tribal Member
 Does not live in contract service area
 Current status not maintained
 Failed to used YDSP provider or YDSP health care facility for
same services
 Failed to use approve the Outside provider
 Prior approval not received for non-emergency service
 No notification within 72 hours for emergency or urgent care
service
 No notification within 30 days for emergency or urgent care
service if patient is an elder (65 and older) or disabled
 Health care services were not medically necessary
 Health care costs are not reasonable
 The medication is not generic
 Failure to exhaust all alternate resources
 Failure to sufficiently document claim
 Failure to notify CHS of scheduled/rescheduled appointments
 Services are not allowable under Priority Status of Medical
Needs
 There are no CHS Funds
Tribal Members’ refusal to participate and contribute to their own health through preventive care
programs such as diabetes education, tobacco awareness, dental screening and cleanings,
optometry screenings, yearly wellness exams at YDSP health care facility, and to keep
appointments shall be considered by the CHS Committee making its denial determinations.
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RECONSIDERATION AND APPEALS
CHS will email or mail a certified letter person to whom contract health services are denied
stating the reason for the denial of payment. The notice shall advise the applicant for contract
health services that within 30 days from the receipt of the notice the applicant:
 May obtain a reconsideration by the appropriate CHS Committee of the original denial if
the applicant submits additional supporting information not previously submitted; or
 If no additional information is submitted, may appeal the original denial by the CHS
Committee to the appropriate Area or program director. A request for reconsideration or
appeal shall be in writing and shall set forth the grounds supporting the request or appeal.
If the original decision is affirmed on reconsideration, the applicant shall be so notified in writing
and advised that an appeal may be taken to the Area or program director within 30 days of
receipt of the notice of the reconsidered decision. The appeal shall be in writing and shall set
forth the grounds supporting the appeal.
If the original or reconsidered decision is affirmed on appeal by the Area or program director, the
applicant shall be so notified in writing and advised that a further appeal may be taken to the
Director, Indian Health Service, within 30 days of receipt of the notice. The appeal shall be in
writing and shall set the grounds supporting the appeal. The decision of the Director, Indian
Health Service, shall constitute final administrative action.
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ANNEX A
PRIORITY STATUS OF MEDICAL NEEDS
The system of medical needs priorities remains necessary to assure that available CHS funds are
appropriately expended for services in accordance with IHS Guidelines. The current CHS
Priority of Medical Needs schedule is as follows:
Priority One
Services required preventing immediate death or serious impairments:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Obstetric and Pediatric Emergencies
Cancer Treatment
Eye Emergencies
Psychiatric Emergencies
Dental Emergencies
Hemodialysis
Emergency Transportation
Surgical Emergencies
Special Shoes for diabetics must meet at least one of the following criteria:
a)
documented loss of sensation of the foot
b)
previous foot ulcer
c)
previous amputation
d)
severe deformity of the foot
e)
evidence of internal hemorrhage or other pre-ulcer changes
10. Immunizations
11. Ear, nose and throat surgery when immediate threat to development of speech, language
and hearing is documented
12. Gynecological tubal ligation when documented high risk medical conditions exist and
subsequent pregnancy poses threat to life of mother or infant
Priority Two
Services for potentially life-threatening/severe handicapping conditions:
1. Laboratory/Radiology/Nuclear Medicine not available on site including screening
mammography
2. Specialty consultation: For acute care diagnosis, cancer, high risk OB
3. Back fill for positions: lab, x-ray, pharmacy, MD, nursing
4. Psychiatric ambulatory and inpatient services
5. Non-emergency elective surgery
6. Podiatry services-high risk medical
7. Prosthetics and Appliances
8. Psychiatric care with psychiatrist and counseling with Social Services
Priority Three
Services, which contribute to better patient functioning, but not necessarily to prevent death or
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serious impairment:
1.
2.
3.
4.
5.
6.
7.
Patient rehabilitation
Specialty consultation when less than Priority Two
Hearing Aids
Podiatry/Orthopedics-less than Priority Two
Allergy services
Second opinions (to be approved by the CHS Committee on a case by case basis)
Orthodontic services (non-cosmetic)
Priority Four
Services, which are elective or indefinitely deferrable:
1.
2.
3.
4.
5.
Long-term residential psychiatric care
Preventive medicine
Non-emergency transportation
Any elective sterilization procedure
Physicals
Failure to follow any of the guidelines will be handled by the CHS Committee on a case-by-case
basis.
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