Contract Health Service Program Questions and Answers
Carolyn Gougé, CHS Administrator
The Red Cliff Community Health Center provides two types of health services: "Direct" and "Contract Health Services" (CHS). These two types of services each have their own set of rules and guidelines.
What is Direct Care?
Direct Care is services provided at the Red Cliff Community Health Center. Examples of direct care include physician care, optical dispensing, pharmacy, podiatry care, laboratory, x-ray and dental care
What is Contract Health Service?
These are health services that are purchased from public or private facilities. These are health services not available at the Red Cliff Health Center. Examples include Specialty Consultations such as Cardiac Care, Urology, Neurology, Orthopedics, and Hospitalizations.
Am I eligible for Contract Health Services?
A. Eligibility requirements include an application process (this process must be done yearly or as situations change). Documents required include the following:
- Verification of Residency (due to regulations we can only serve those Red Cliff tribal members residing with-in Bayfield County, our Contract Health Service Delivery Area). We serve other tribal members only if they reside on the Red Cliff Reservation
- Documentation stating you that you are ineligible for Medicaid.
- Monthly Household Income
- Documentation of membership in a federally recognized tribe
- Primary Insurance (if applicable)
How can I get Contract Health Service to pay for my medical care?
No payment will be made for medical care/services obtained from private medical vendors unless:
- Eligibility has been determined.
- A purchase order has been issued prior to obtaining medical care.
- In an emergency the client or individual or agency acting on behalf of the client shall within 72 hours after the beginning of treatment or admission notify the Contract Health Service Program of the admission of treatment. A review of the emergency room notes will take place to determine the medical priority
Payment will be authorized for those medical services that are identified as Priority 1A: Emergency threat to Life, Limb, and Senses. This includes the diagnosis and treatment of injuries or conditions that, if left untreated, results in uncertain/potentially grave outcome.
Notification requirements apply to all categories of people, including students, transients, and persons who leave the Contract Health Service Delivery Area.
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:
- Eligibility Not Established
- Alternate Resources Available
- No Notification of Emergency Service With-In 72 Hours
- Insufficient Medical Information (emergency room notes not sent to Red Cliff)
- Red Cliff Community Health Center Was Available to Provide Care
- Care Not With-In Medical Priority
- Lack of Funds
- Lives Outside Of the Contract Health Service Delivery Area, Bayfield County
- No Prior Authorization for a Scheduled Service
- No Notification of Emergency Service With-in 30 days for Elderly or Disabled
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 within 30 days. You should bring the statement into the Contract Health Program for a review.
The Red Cliff Community Health Center provider gave me a referral why is the Contract Health Service Program denying the authorization of payment.
A physician's referral does not constitute a guarantee of payment for any services. Due to limited dollars some Contract Health Service medically indicated referral's are not within established and funded medical priorities, therefore some referral's cannot be paid with Contract Health Service funds.
I'm confused on the Contract Health Program what should I do?
PLEASE STOP INTO THE CONTRACT HEALTH SERVICE PROGRAM WHERE YOUR QUESTIONS CAN BE ANSWERED.
Do you know who authorizes payment for your medical care?
Come and see the Contract Health Service Representative for Questions.