Red Lake IHS Hospital

Contract Health Services

The Contract Health Services is funded annually by U.S. Congress.  It is not an entitlement program or an insurance program.  The IHS cannot guarantee that funds are always available.  The Contract Health Services Program has guidelines set forth which determine the services that it can and cannot pay for. 

Eligibility Criteria

Basic policies and regulations that apply in determining eligibility for Contract Health Services:

• You must be an Indian from a federally recognized tribe.

•  You must reside on-or-near an Indian Reservation within a Contract Health Services Delivery Area (a county containing all or part of a reservation or shares a boundary with the reservation).  Non-members of that particular tribal reservation must reside on the Indian Reservation to be eligible.

You must meet the first two conditions:

• You must utilize all other resources such as Medicare, Medicaid and Private Insurance. IHS is the payer of last resort per Federal Register CFR Part 36.61.
• You must meet specific notification requirements regarding CHS policies and regulations.
• Your referral must fall within the medical priority guidelines which the medical staff determines.

These are general guidelines, there are other CHS eligibility considerations that you may qualify for; these exceptions are handled on a case-by-case basis.



Staff

The CHS staff consists of:

     One Contract Health Specialist
     Two Medical Clerks



Managed Care Process

Contract Health referrals are prioritized by the attending
physician using the Medical Priority Guidelines; these referrals are reviewed by the Managed Care Committee which are held weekly with the medical providers and CHS staff. Emergency referrals are arranged at the time the patient is seen in  ER/Urgent Care. ER records from outside facilities are also
reviewed; purchase orders are issued for the approved visits and letters are generated for the visits that are denied explaining the reason it was denied.

Transportation to Appointments

Transportation is available for patients that are referred to an outside facility.  Referral slips are completed and delivered to the Transportation Director who arranges the trips. Transportation is not provided to patients that prefer to have their routine medical care at another medical facility.

CHS Responsibilities

Medical & dental referrals are received on a daily basis; each referral is researched for other alternate resources that may be available.  Medical referral with active Medicaid are scheduled, all other referrals are reviewed at the weekly Managed Care meeting.  After the meeting the approved referrals are scheduled,   referrals that did not meet the guidelines are documented in the CHS Deferred Report and letters are sent to the patient informing them of the Managed Care decision.

The CHS staff works closely with the Patient Benefit Coordinator (PBC); PBC assists patients with applying for other alternate resources they may be eligible for.   PBC contacts patients regarding alternate resources and explains the importance of completing the alternate resource application.