Contract Health

SERVICES PROVIDED

EMERGENCY MEDICAL ASSISTANCE
The Emergency Medical Assistance (EMA) program is a tribal program that provides assistance to eligible Creek citizens regardless of where they live in obtaining:

• Prescribed medications not available within a tribal or IHS health facility (no over the counter medications)
• Prescribed medical equipment necessary to sustain health and well-being (oxygen, concentrators, walkers)
• Prosthesis (artificial limbs)

This program is not intended to cover the total cost of prescriptions and related expenses. An application must be initiated at one of our health facilities and eligibility must be established prior to receiving assistance. There are benefit limit amounts for each category and applicant must furnish documentation verifying all other available resources (Medicaid, Medicare, Private Insurance, etc.) have been exhausted.

BENEFIT LIMITS

• Health Maintenance: $2,500 per year
• Life Sustaining: $5,000 per year

Emergency Call-In Procedures
Emergencies must be reported within 72 hours after the beginning of treatment or admission to a health care facility. The notification is extended to 30 days for the elderly 65 years of age or older who have a limiting physical condition that prevents them from notifying CHS. Steps to follow when calling:

1. Call 918.758.2710 x 4363 or toll-free 877.435.2323

2. Speak with a case manager who will take your information and ask specific questions regarding your emergency

3. If case manager is unavailable, leave your name and number. If after-hours or weekends, your call will be returned the first business day.

TRIBAL VISION PROGRAM

The Tribal Vision Program provides assistance to eligible Creek citizens who reside within the State of Oklahoma in obtaining a vision examination and eye glasses. Citizens are eligible every two years for this program and must fill out an application and follow these general guidelines:

• Applicant must use MCN contracted optometrist or any Tribal/IHS facility optometrist
• CONTRACT PROVIDER: Prior approval must be obtained before an appointment can be scheduled with the contract optometrist
• TRIBAL FACILITY: Applicant must provide their prescription or order form from the optometrist and it must be written within a 6-month period
• Payer of last resort meaning all resources must be utilized first and there is a benefit limit for exam ($60.00) and glasses ($240.00)

Funding is expended based on priority guidelines with enrolled original allotters and children 18 years of age and under receiving the highest priority.

For any questions please call the number below.

Sarah Taylor – Tribal Vision Program: 918.758.2710 ext. 4358

Click here for application.

Frequently Asked Questions

What is Contract Health Services?

A federally funded (and some instances tribally funded) program that assists with payments to “outside” medical facilities/physicians for services received by an eligible American Indian/Alaska Native and Non-Native patients.

Assistance depends on eligibility, residence, medical priority, alternate resources and availability of funding.
We are not an insurance company!

Who is eligible for CHS?

Anyone who can provide proof that they are a member of a federally recognized tribe.
Tribal Citizenship Card
Certificate of Degree of Indian Blood (CDIB) Card
Verification Letter from Tribal Citizenship Office
Non-Native woman pregnant with an eligible Indian’s child.
Eligible individual must have a permanent address within CHSDA area.

How do I get a referral?

Must be seen by a doctor at a Tribal or IHS facility. That physician will then determine if outside services are needed for the patient.

If the patient was seen by an IHS or Tribal physician outside their CHSDA area; that facility must fax the referral to appropriate CHS office.

Eligible person went to a non-Tribal/IHS Emergency Room or Hospital for care, that patient or guardian must call in to proper CHS office within 72 hours or 30 days for elders.

**A referral is not a guarantee of payment for services, it is a request for payment for services.**

Why aren’t my bills getting paid?

Referrals must be approved before payment can be made.

•Clinical CHS staff/Outside CHS staff/Hospitals/patients must submit requested referral/call-in documentation to CHS office for review. (By Friday)

•CHS Case Managers review referrals and prepare them for the Medical Review Committee. (On Tuesday)

•Medical Review Committee prioritizes and ranks each referral.

•Referrals are then given to Account Support Specialist for estimated pricing, then given to CHS Financial Analyst.

•CHS Financial Analyst then starts to distribute money to the referrals going in order of priority until funding is exhausted.

•Approved/Denied referrals are given back to Account Support Specialist for Purchase Orders (PO) to be mailed out for approved referrals and Denial letters to be mailed out to patients and vendors for those that were denied.[/vc_column_text]

When can vendors expect payment?

PO/Claim/EOB must be received by the Accounts Support Specialist Dept.
If claim is submitted without PO or referral, claim will be sent to the bill processor for distribution to Account Support Specialists.
Claims will be re-priced to Medicare Like Rates (MLR), unless in a contract with vendor; or has a primary insurance.
All hospital claims will be re-priced to MLR, if patient has PVI we will only pay up to the MLR amount. If the PVI paid more than MLR, no payment will be made & balances are to be wrote off.
Claims are documented in the CHS system (WADE) by code and payment rate.
Payments are entered into the financial system (LincDoc) for approval by CHS Manager, once approved it is then transferred to Finance Dept. for Vendor verification and check processing.

Checks are received from finance, logged into the CHS system (Laserfiche), then mailed out with an EOB.
Process takes about 2-4 weeks.

What is a CHEF Case?

Catastrophic Health Emergency Fund
High dollar services, such as Cancer, Burns, High-Risk Births, Cardiac Disease, End-Stage Renal Disease, Strokes, etc.
All alternate resources and a $25,000.00 threshold must be met by the Tribal/IHS facility before reimbursements can be expected.
Cases are submitted to Area Office and reviewed then submitted to IHS Headquarters.
Reimbursement is based on First In First Out (FIFO).

My referral was denied….What do I do now?

All Denied Referrals can be APPEALED!!
The patient or someone acting on behalf of patient has 30 days from date of the denial letter to submit an appeal letter to the Creek CHS department.
Appeals are reviewed and processed to Medical Appeal Committee.
Medical Appeal Committee meets the 2nd Wednesday of the month.
After review of the Appeal Committee, a letter is mailed to patients and vendors with the decision of the Appeal.
Referrals can be appealed up to 2 times with written letters/documentation.