Coverage for Services

 

Current Criteria to be eligible for Direct Patient Care

 

Direct Health Care Service: 

Direct patient care services is defined as all services healthcare services that are provided by EMHC and field clinics to eleigible registered patients. Direct patient care does not include Purchased and Referred Care referrals. Direct Services and Purchase and Referred Care have separate criteria as determined by the federal government, congressional appropriation, and the Three Affiliated Tribes. 

 

Below is the criteria to recieve direct health care services at EMHC or any of our field clinics: 

1. Must enrolled member of a federally recognized U. S. Indian Tribe. Official and original forms/documentation are required to receive services.

2. Can be descendant of an enrolled member of a federally recognized U. S. tribe. Formal documentation must be provided as verification from the tribal enrollment Bureau of Indian Affairs when available. Additional documentation may be required such as a birth certificates connecting you to an enrolled member of a federally recognized tribe.

3. Pregnant non-Indian female maybe eligible for direct patient care and may need to provide a marriage license or notarized statement of paternity co-signed by an enrolled member of a federally recognized U. S. Indian tribe. Non-Indian females who meet the requirements above are eligible for care as it is associated with pregnancy. Verification is required and will allow for all prenatal visits and one 6 week post pregnancy follow up visit. 

4. Non-Indian children who are adopted, fostered, or stepchildren of an eligible Indian are eligible for direct patient care. In such cases, a child is eligible until age 19.  Documentation must be provided (court documentation of foster placement, etc).

5. Commissioned Corps members or immediate family are eligible for direct patient care. The patient must provide proof of Commission Corps status.

6. Non-Indian service unit employees are eligible for services associated with the Employee Health Program, which does not include routine health care. The specific types of care included can be found in the Employee Health Manual and are approved by the Infection Control Committee, the Chief of Medical Staff, and the Chief Executive Officer.

7. Due to the public's health and communicable diseases such as sexually transmitted infections (STIs) and potential public health epidemics, the treatment of a non-Indian is deemed necessary by a medical provider to prevent or contain the spread of a disease or public health epidemic, and such treatment shall be allowed. Non-natives being treated due to this allowance will be required to register as patients for such treatment. Patient registration will create a non-beneficiary chart for the individual. Elbowoods Memorial Health Center and field clinics can recover and bill for services rendered to non-beneficiaries. 

8. Emergency care is unavailable through EMHC and field clinics, and all emergencies will be sent to the closest critical access hospital. 

Purchased & Referred Care (or PRC, formerly Contract Health Services):

PRC is a financial resource program meant to assist patients in payment for referred care that facilities and specialist healthcare provide through EMHC and Tribal Field Clinics. Purchased and Referred Care is not an entitlement program for American Indian and Alaska Natives as it is a Congressional Appropriations and all patients are required to be assessed for qualification of what is called an alternate resource such as private insurance (associated with work insurance), Medicaid/Medicare, and Medicaid Expansion. 

 

Purchased & Referred Care (formerly Contract Health) eligibility criteria:

1. Patients must be enrolled in a federally recognized tribe and reside within the boundaries of the Ft. Berthold Indian Reservation. This is called the Contract Health Service Delivery Area (CHSDA).  The Ft. Berthold Service Area includes Mountrail, McKenzie, McLean, Mercer, Dunn, and Ward counties in North Dakota. Proof of residency is required to determine PRC eligibility. You must provide a valid ID with your current physical address, if that is not available, proof of residency (rent receipts, utility bills, etc.) will be required.

2. Descendent of an enrolled member of the Three Affiliated Tribes who reside within the boundaries of the Ft. Berthold Reservation, and maintain economic and social ties with the Tribes of the Ft. Berthold Reservation (i.e., work on this Reservation, or have family on this Reservation) are eligible for PRC.  Documentation verification of descendency is required along with proof of residency (rent receipts, utility bills, etc).

3. Patient who were previosly PRC eligible and are now full-time student (in-person program), dependent of, or foster child and residing else where may be eligible for PRC. Proof of college enrollment and registration for every semester is required to remain eligible for PRC as a college student. This is the responsiblity of the student to provide thier enrollment in college. This does not include on-line web-based enrollment.  

4. Patient who move outside of the CHSDA area are covered by PRC for up to 180 days.   

Difference between “Referral” and “Authorization”:

1. A “Referral” is a recommendation for specialty care not available locally by an EMHC and field clinic provider. Referrals are made based on medical determination of need. A referral is not a guarantee of payment. Providers use their clinical judgment to determine the medical necessity for further evaluation and testing and may refer you to a specialist. All referrals are sent as written by providers, but not all referrals are paid for by PRC, and all patient requirements must be met to be eligible for payment. PRC does not cover self-referrals and is the responsibility of the patient. *Always obtain a referral from your provider.

2. An “Authorization” is a guarantee of payment given when the Referral is within the funding priorities. These vary, depending on the availability of funds.  The level of care authorized by this clinic relies on the amount of money received from Congress through the IHS system and additional funds provided by the Three Affiliated Tribes to supplement the PRC program. An authorized referral required that all private and public insurance are billed prior to PRC paying for referred care. All Authorized patient claims are required to be repriced at Medicare Like Rates (MLR). 

3. A denial of a referral is simply a denial of payment. All referrals are sent as a written order from a provider, but not all referrals are eligible for payment and/or a priority of Purchased and Referred Care. If you have any questions, you can contact the PRC Manager and have the right to appeal the payment determination. 

For a patient to get their hospital or speciality care bills paid, the following is required:

1. All patients must meet the eligibility requirements regarding Indian descent and residency within the Contract Health Service Delivery Area (counties of Mountrail, McKenzie, McLean, Ward, Mercer, and Dunn).

2. All patients must have an authorization referral for the evaluation and/or treatment of non-emergency care.

3. All eligible PRC patients must notify the Purchased and Referred Care office at the Elbowoods Memorial Health Center within 72 hours of any emergency treatment received at a facility such as an Emergency Room or Urgent Care. Care that can be provided during operational hours by EMHC and field clinics is not authorized for payment. * Elders are allowed a grace period of 30 days to provide notification to EMHC PRC. In addition, to notifying EMHC PRC of an emergency visit, it is always important to provide information of your health insurance coverage when ever possible to the emergency departmental registration as well as providing accurate contact information. If you have private insurance such as employee health insurance,Medicaid, Medicare or the Market Place please provide the facility that information and inform the registration that Elbowoods Memorial Health Center is a secondary payor source. 

4. All patients must have a reasonable belief that emergency treatment they seek at an outside facility is a true emergency and constitutes a threat to life or is required to prevent permanent bodily harm or disability if treatment is not immediate. Primary care by way of emergency care is not considered a priority and may be at risk of being denied payment. Determination and priority are determined by the PRC Committee.

5. All patients are required to apply for alternate resources (Medicaid, Medicare, Veterans benefits, Medicaid eligible waiver programs such as Autism Waiver, auto insurance (liability), vocational rehabilitation, workman's compensation, ND Women's Way, etc.) if it is reasonable to believe you may qualify. Speak with a Benefits Specialist who can assist with the application process to obtain an alternate resource. 

6. All patients are recommended to contact the Purchased & Referred Care (PRC) and/or Patient Services Benefits office immediately at the Elbowoods Memorial Health Center if the patient has a question about a bill. The PRC office requires an Explanation of Benefits from the facility the patient visits. 

7. All patients who require specialty care must obtain periodic updated referrals as PRC provides a limited number of approved encounters. Your primary care provider must update the referrals. Secondary referrals from the specialist must be brought to the attention of your Primary Care Provider. This includes scheduled follow-up visits associated with Emergency Room care or surgical care. If you have any questions related to your referral please contact Purchased and Referred Care.