Contract Health Services
Contract Health Services is a restricted Federal Program of managed care for a limited population. It is designed to provide for the payment of a limited number of services not available at our clinic, according to special priorities or levels of care. Examples of such services would be X-ray, emergency room, laboratory and referrals to other medical and dental specialties. There are five general medical priority levels:
Emergency/Acutely Urgent Care
Acute Primary & Preventive Care
Chronic Primary & Secondary Care
Chronic Tertiary & Extended Care
SCIHP is authorized to provide for the first three levels only (I, II, and III), when it is determined to be medically necessary. Patients should note that most Level II services and many in Level III are available directly from SCIHP. At the present time, inpatient hospital care is not a covered benefit.
In order to qualify for Contract Health Services, you must meet certain Federal requirements. In general, you must:
- Provide documentation that you are an
American Indian from a federally recognized tribe that is native
- Reside within SCIHP’s service delivery
area and within a Contract Health Service Delivery Area
(“CHSDA”). Nearby counties, which are not part of the CHSDA
and Solano. Napa
- Apply for all other health resources for which you may be eligible, such as private insurance, Medi-Cal, Medicare, California Children’s Services; an application for the Healthy Families Program is also available. Our Patient Services Coordinator is available to assist you in this process and answer any questions you may have. This is a federal requirement since the Indian Health Service is the payer of last resort only.
- Meet specific notification requirements.
An example would be the requirement to notify the
CHSCoordinator within 72 hours of any emergency treatment you may have received.
- Services must be authorized by a SCIHP medical, dental, or behavioral health provider.
- Obtain prior approval from the
CHSProgram. A government purchase order is then issued to officially authorize the requested services.
When a SCIHP physician, dentist, or other authorized provider makes a referral to an outside consultant or service, such a referral within itself does not constitute a commitment for payment by the Indian Health Service. Only the official government purchase order is able to obligate federal funds, and must be obtained in accordance with the guidelines listed above.
Denial and Appeals
In the event it is necessary to deny payment for outside care, a denial letter is formally issued, which states the reason for the denial and the procedure for appealing the decision. You are allowed a thirty (30) day period to appeal in writing at the local level to: Sonoma County Indian Health Project, Inc., Attention: Chief Executive Officer, 144 Stony Point Road, Santa Rosa, CA 95401
If the appeal does not result in a reversal of
the decision at the local level, you are entitled to a final appeal
in writing to:
California Rural Indian Health Board, Inc., Attention:
This constitutes the final administrative action available to you.
The principal reasons for denial of payment are:
Ineligible for Contract Health Services (i.e., no documentation of Indian descendancy, does not meet residency requirements, etc.).
Failure to obtain prior approval (patient referral) for non-emergency services.
Failure to provide notification to the
CHSProgram within 72 hours of receiving emergency care.
Failure to follow and comply with all regulations regarding an alternate resource for which the patient may be eligible (i.e., refusal to apply for Medi-Cal, failure to become active for Medi-Cal, etc.).
All bills must be submitted to the
CHSCoordinator, within 180 days from the date of service. Any bills received after the 180 days, will not covered by SCIHP.
Service requested is not within the established priorities of care.
Sonoma County Indian Health Project’s