CONTRACT HEALTH SERVICE (CHS)
Contract Health Service is a federal funding source designed to provide specialty care services to eligible Native Americans when services are unavailable at a tribal clinic. With PRIOR AUTHORIZATION the following services may be covered by CHS : medical, dental, pharmacy and optical.
To be eligible for CHS you must be an enrolled member of the Cowlitz Tribe and reside within the Tribe’s ten county Contract Health Service Delivery Area (CHSDA). There are exceptions to this general rule for students and pregnant women.
If the two requirements above apply then you must submit an application for services (Tribal Enrollment and CHS registration are two separate applications). Please be aware that CHS cannot back date eligibility. The following documents will be required prior to an eligibility determination and in some cases annually thereafter:
- Tribal ID
- Insurance Cards (Medicare, Medicaid, Regence, VA, etc.)
- Proof of Residency
- Birth Certificate
- Photo ID and/or Social Security Card
- Application for medical from the Department of Social and Health Services if you are uninsured or become pregnant, blind or disabled.
- Receiving Primary Care at the Cowlitz Tribal Health Clinic in Longview if you reside within 60-miles of the clinic.
Once you are deemed eligible two cards will be mailed to you, one for CHS and the other for pharmacy (NWPS). Please keep your cards with you and provide them as appropriate. Instructions and brochures will also be provided (please keep all documents provided to you for future referrance).
CHS operates within four levels of priority ranging from 1‡4, 1 being “Threat to LIFE” or LIMB, 4 being Rehabilitation. As funds become depleted the Health Board may make the determination that services be restricted to LIFE or LIMB only. If this occurs CHS staff will maintain a DEFERRED SERVICES list and services will be made available as funds become available. If funds become depleted pharmacy cards may be turned off.
CHSDA Counties: Skamania, Clark, Cowlitz, Columbia, Lewis, Thurston, Pierce, King, Kittitas and Wahkiakum.
Relocating to the CHSDA? A sixty day waiting period will apply to Members moving into the CHSDA, this period will begin once acceptable proof has been provide to the CHS office.
Contract Health Service will continue to cover Members moving from the CHSDA for a period not to exceed 90 days.
Each and Every visit requires a prior authorization. After making your appointment you must call CHS to provide notification of the visit to include the appointment date and name of clinic or provider. Each visit is assigned an authorization number and funds are set aside for your visit. This will allow CHS to monitor remaining funds so that we may alert the Health Board if funds become depleted or low. In the event of a catastrophic injury or illness staff must be aware of available funding. Each catastrophic case is carefully monitored for alternate resources.
Time frame for notification: At least 48 hours prior to your appointment, however two weeks is preferred. If you requested an authorization and there is a ZERO balance please notify staff so those funds can be used for other services.
Receiving a bill after you notified CHS?
**If you provided notification of your visit to the CHS office and receive a bill from your provider you can assume that CHS has not been billed. Please contact the provider and request that they bill CHS. There may be several charges associated with a visit that CHS is unable to foresee. DO NOT wait for a collection notice to be sent, follow up with your provider as soon as possible.
If you have sustained a life threatening illness or injury and were treated at the emergency room you or someone acting on your behalf must notify CHS within 72-hours. Immediate notification is encouraged but not always possible.
An emergency is not defined by the location of treatment but by the immediate need for medical care. A medical necessity review will be completed by a Tribal provider who will then make recommendations to CHS as to the appropriateness of treatment. Payment is based on this recommendation.
If your emergency room visit is not deemed a true emergency you may become responsible for your bill. All urgent care visits require PRIOR AUTHORIZATION. If you are calling after hours please use the answering system to leave CHS a message.
Alternate Resource Rule
Contract Health Service is considered “payer of last resort” by federal regulation and utilization of all alternate resources is required. Forms of alternate resource include but are not limited to the following: Medicare, Medicaid, private insurance such as Regence or Aetna, Veteran’s Administration (VA) and tribal clinics.
To avoid CHS denials please ensure that you are meeting all program requirements. If you do not have an alternate resource (any other source of payment) and fail to complete the state medical application you will not be eligible for CHS payment. It is also very important to understand the rights and responsibilities of your alternate resource such as the VA.
Denials and Grievances: Upon receipt of a CHS denial, members have 30 days to submit their written request for reconsideration to the Tribal Health Director. If you are not satisfied with the decision of the Tribal Health Director the third and final step of the appeal should be submitted to the Managed Care Committee. If you feel that you have a grievance or complaint, please state your case in writing to the Tribal Health Director.