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 anenrolled member of the Cowlitz Tribeandreside 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 forservices(Tribal Enrollment and CHS registration are two separate applications).Please be aware that CHS cannot back date eligibility. The following documentswill be required prior to an eligibility determination and in some cases annuallythereafter:
- 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 ifyou are uninsured or become pregnant, blind or disabled.
- Receiving Primary Care at the Cowlitz Tribal Health Clinic in Longview if youreside within 10-miles of the clinic.
Once you are deemed eligible two cards will be mailed to you, one for CHS and theother forpharmacy (NWPS). Please keep your cards with you and provide themas appropriate. Instructions and brochures will also be provided (please keep alldocuments provided to you for future referrance).
CHS operates within four levels of priority ranging from 1‡4, 1 being “Threat toLIFE” or LIMB, 4 being Rehabilitation. As funds become depleted the Health Boardmay make the determination that services be restricted to LIFE or LIMB only. If thisoccurs CHS staff will maintain a DEFERRED SERVICES list and services will be madeavailable as funds become available. If funds become depleted pharmacy cards maybe 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 Membersmoving into the CHSDA, this period will begin once acceptable proof has beenprovide to the CHS office.
Contract Health Service will continue to cover Members moving from the CHSDA fora period notto exceed 90 days.
Each and Every visit requires a prior authorization. After making yourappointment you must call CHS to provide notification of the visit to includethe appointment date and name of clinic or provider. Each visit isassigned anauthorization 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 becomedepleted or low. In the event of a catastrophic injury or illness staff must be awareof available funding. Each catastrophic case is carefully monitored for alternateresources.
Time frame for notification: At least 48 hours prior to your appointment, howevertwo weeks is preferred. If you requested an authorization and there is a ZERObalance 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 fromyour provider you can assume that CHS has not been billed. Please contact theprovider and request that they bill CHS. There may be several charges associatedwith a visit that CHS is unable to foresee. DO NOT wait for a collection notice to besent, follow up with your provider as soon as possible.
If you have sustained a life threatening illness or injury and were treated at theemergency room you or someone acting on your behalf must notify CHS within 72-hours. Immediate notification is encouraged but not always possible.
An emergencyis not defined by the location of treatment but by the immediate needfor medical care. A medical necessity review will be completed by a Tribal providerwho will then make recommendations to CHS as to the appropriateness of treatment.Payment is based onthis recommendation.
If your emergency room visit is not deemed a true emergency you may becomeresponsible for your bill. All urgent care visits require PRIOR AUTHORIZATION. Ifyou are calling after hours please use the answering system to leave CHS a message.
Contract Health Service is considered “payer of last resort” by federal regulation andutilization of all alternate resources is required. Forms of alternate resource includebut are not limited to the following: Medicare, Medicaid, private insurance such asRegence 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 tocomplete the state medical application you will not be eligible for CHS payment. It isalso very important to understand the rights and responsibilities of your alternateresource such as the VA.
Denials and Grievances:Upon receipt of a CHS denial, members have 30 days tosubmit their written request for reconsideration to the Tribal Health Director. If youare not satisfied with the decision of the Tribal Health Director the third and finalstep of the appeal should be submitted to the ManagedCare Committee. If you feelthat you have a grievance or complaint, please state your case in writing to the TribalHealth Director.