CHS guide for beneficiaries 2014

Table of Contents 1) Income Verification"2) Pharmacy"3) Emergency Room Use"3) Nurse Hotline"3) Denial Process"4) Alternate Resources"4) Road Travel"4) Proof of Insurance"4) Wellness Services"5) Referrals to ANMC & Private Sector, OB Care"5) Dental Services"ACA Exemption"6) Patient Responsibilities"6) Patients Rights

Contract HealthA Reference Guide for "

SVT Health & Wellness Beneficiaries

SVT Contract Health Services!Who? Contract Health Services are provided to all Alaska Natives

and American Indians, who live in the Homer/Seldovia area for more than 180 days (6 months).!

What? Contract Health Services provide preventive medical and dental coverage, OB coverage, routine medical care, labs, x-ray and emergent care.!

Why? Seldovia Village Tribe is a federally approved Contract Health Service Delivery Area.!

When? Beneficiaries are asked to register for Contract Health Services when the 180 day waiting period ends. !

Where? SVT Health & Wellness facilities in Homer or Seldovia.!Please be sure to bring all documentation showing proof of

eligibility: such as Certificate of Indian Blood, Tribal Enrollment Cards, Birth Certificate, and proof of residency.!

ANNUAL INCOME VERIFICATION

As your Community Health Center, SVT Health & Wellness (SVTHW) requires each Contract Health Service beneficiary to complete a short form listing the people in his or her household, as well as income once per calendar year. This information will then be given to SVT’s Tribal Secretary for verification as eligible beneficiaries. This is to enable SVTHW to continue to offer high quality health coverage to our beneficiaries.

Trinket Gallien"Assistant Director

Without this information your unrestricted Health Services atSVT Health & Wellness will become self pay.

SVT HEALTH & WELLNESS

HOMER 880 E. END RD 226-2228 | SELDOVIA 206 MAIN ST. 435-3262 "PAGE �1

PRESCRIPTIONS

RE ORDERING MEDICATIONS FROM VILLAGE PHARMACY

It is ALWAYS your choice where you receive treatment, but you must be aware of and understand that any referrals outside of the guidelines of this policy will result in you being outside of the umbrella of coverage by either Seldovia Village Tribe or ANMC. In

such cases, you will personally be responsible for medical costs incurred.

When your provider has prescribed medications that require monthly refills from Alaska Native Medical Center Village Pharmacy, it is your responsibility to re-order these medications monthly.!

Here is how: !1. Reorder when you have 10 days

of medication remaining.!2. Call toll free 1-800-365-1104!3. Be prepared to leave the

following information.!a. Your full name!b. Date of birth!

c. Your RX number and phone number!d. Name of medication you are requesting to

be refilled.!Medications will be refilled and mailed to the address you requested.!Please note: You will need to leave a message on the answering machine and you will not be speaking with a pharmacist.!If you have not received your medication

within 7 days you will need to call 1-800-365-1104 and leave a message stating medication hasn’t been received.!

W h e n e v e r p o s s i b l e , medications prescribed for you at SVT Health & Wellness will be dispensed from our Pick Point machines on site or ordered from Alaska Native Medical Center ’s Village Pharmacy.!

Medications from either of these are provided at no cost to you.!

I f t h e p r e s c r i b e d medication is not available at SVT Health & Wellness facilities or you need this medication urgently, a provider will write a prescription for up to 10 days medication. This urgent prescription can only be filled at Ulmer’s Pharmacy in Homer. Prescriptions needed for longer than 10 days and are

not filled as stated become the patient’s responsibility as self pay!

SVTH/W Does not Cover:!Sleeping medication, all

non-urgent and chronic medications. These MUST be ordered from ANMC Village Pharmacy.!

All over-the-counter medications such as Ibuprofen, C l a r i t i n , P r i l o s e c , a n d Naprosyn.!

Controlled medications, except for acute injury or condition only, up to a 10 day one-time supply.!!

SVTH&W is a payer of last resort, all other forms of

coverage must be exhausted first.

SVT HEALTH & WELLNESS

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EMERGENCY ROOM USE

WHAT TO DO WHEN RECEIVING A DENIAL LETTERSeldovia Village Tribe Contract Health has

limited funding to provide services to you our beneficiaries. It is important that you understand what is covered with this funding and what is not. The requirements are from the Federal Government through Indian Health Services it is the law. !

Any request for reconsideration or appeal must be in writing within thirty (30) days from the date denial letter is received.!

When a denial letter is received here are your options for an appeal. !

1. Read denial letter in its entirety. !2. If the service performed at South Peninsula

Hospital was not a referral from SVT Health & Wellness the bill will automatically be self pay. !

3. Non-Emergencies treatable at SVT Health & Wellness will be self pay.!

4. Alcohol or drug related visit is self pay!5. By law Seldovia Village Tribe Contract

Health Care funds are the payer of last resort. You must apply for all alternate resources available. (see page 3)!You may request a reconsideration or an appeal to denials by sending additional information not already submitted to SVT at the following address: !

Seldovia Village Tribe!Contract Health!P.O. Drawer L!Seldovia, Alaska 99663 !Fax: 907-234-7865!Email: [email protected]!

SVT Contract Health will pay for true ‘life and limb’ emergencies. For e x a m p l e l o s s o f consciousness, chest pain, stroke symptoms or respiratory distress.!

We ask that you use your best judgement. If you are ill during the day, call SVT Health & Wellness and come in for a visit. Evenings call SVT Health & Wellness nurse hotline, don’t wait until a c r i s i s d e v e l o p s . Conditions such as a

recurrent migraine , earache, toothache, flu or cold don’t warrant a trip to the ER and your request for coverage will be denied. Unfortunately, we don’t have the f u n d i n g t o c o v e r emergency room visits for non-emergencies.!

Emergency care is defined as an acute medical condition, sudden in onset with severe symptoms posing an immediate threat to life, limb, or organ. An e m e r g e n c y r e q u i r e s immediate treatment by a physician. !Medical conditions in which a delay in care would be hazardous to life or would result in serious complications are also considered.

- Nurse Hotline - ! Before going to the

Emergency Room call SVT Health & Wellness Nurse

Hotline at 226-2228.

SVT HEALTH & WELLNESS

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ALTERNATE RESOURCES ROAD TRAVEL REIMBURSEMENT

As specified in Title 42 CFR § 136.61 of Indian Health Service Manual, the IHS will no longer pay an AI/AN patient’s medical bills under protest because the patient refused to apply for alternate resources.!These include: Medicare, Medicaid, employer provided group health insurance and the SVT Health Center & Wellness (SVTHW) Sliding Fee Scale. "

All beneficiaries MUST sign up for alternate resources Medicaid, Medicare, and Denali Kid Care if they qualify. An appointment can be made with our Community Resource Coordinator at our Homer facility, or with our Community Health Representative at our Seldovia office.!!

SVT Beneficiaries are eligible for road travel reimbursement when referred from SVT Health & Wellness for treatment at the Alaska Native Medical Center (ANMC). !Ask our Community Resource Coordinator for this form when a referral to ANMC is prescribed.!Travel reimbursement forms must be signed by a SVT Health & Wellness representative before travel to appointment. While at ANMC patient must have the nurse or doctor sign off on the form proving the patient went to their appointment. !Travel reimbursement forms need to be returned to SVT Health & Wellness no later then 10 days after appointment to be considered for payment.!Payments are sent out every three months February, May, August, and November.

Beneficiaries with private i n s u r a n c e , m e d i c a i d , medicare, must provide a copy of health coverage when visiting SVT Health & Wellness. Without this i n f o r m a t i o n y o u r unrestricted Health Services at the SVT Health & Wellness will become self pay. Contract Health by Federal Law is a payor of last resort and all other resources must be exhausted first.

PROOF OF INSURANCE

It is ALWAYS your choice where you receive treatment, but you must be aware of and understand that any referrals outside of the guidelines of this policy will result in you being outside of the umbrella of coverage by either Seldovia Village Tribe or ANMC. In

such cases, you will personally be responsible for medical costs incurred.

WELLNESS SERVICES COVERED UNDER SVT CONTRACT HEALTH:"

• Visits to our on-staff Naturopathic Doctor!

• Naturopathic labs !

• CommunityAcupuncture

“We strive at incorporating whole body, mind and spirit wellness and healing by looking at

the whole person.”Crystal Collier"President/CEO

SVT HEALTH & WELLNESS

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REFERRALS TO ANMC & PRIVATE SECTOR

Referrals for SVT beneficiaries are to be made to Alaska Native Medical Center (ANMC). There are some exceptions to this policy that will allow for consultation in Homer.!(No consultations are allowed to providers outside of Homer, such as Soldotna, other than to ANMC.) !!Referrals may be made to local (Homer) providers for consultation and recommendations for Seldovia Village Tribe Beneficiaries.!

Diagnostic Radiology may refer to South Peninsula Hospital for basic X-ray, US, screening mammogram !and/or diagnostic- mammogram (not including a biopsy).!!No Referrals: For CT, MRI or Procedures (eg: colonoscopy) !at South Peninsula Hospital !or with any local provider. (Must be referred to ANMC)!!Pre-natal care: SVTHW will provide pre-natal care to all pregnant Native patients who want to deliver at ANMC. SVTHW Providers would

conduct the majority of pre-natal visits and coordinate care with Anchorage Service Unit Maternal Child Health Coordinator. SVTHW may refer to Homer provider of choice if pregnancy is not high risk. (A SVT beneficiary must apply for Denali Kid Care and if denied must give a copy of denial letter to SVT.)

• D0120 Periodic Oral Eval!• D0140 Limited Eval-Problem Focus!• D0150 Comprehensive Eval!• D0180 Comprehensive Perio Eval!• D0210 Full Mouth Xray!• D0220 Periapical first film!• D0230 Periapical ea additional film!• D0240 Intraoral Occlusal Film!• D0270 Bitewings Single Film!• D0272 Bitewings 2 Films!• D0274 Bitewings 4 Films!• D0277 Vertical Bitewings 7+ Films!• D0330 Panoramic Film!• D1110 Adult Prophy!• D1120 Child Prophy!• D1203 Flouride/Child!• D1204 Flouride/Adult!• D1351 Sealent/Per Tooth!• D2140 Amalgam 1 surface!• D2150 Amalgam 2 surface!• D2160 Amalgam 3 surface

DENTAL SERVICES The following are a few procedures covered by Contract Health Services:

• D2161 Amalgam 4+ surface!• D2330 Resin 1 surface anterior!• D2331 Resin 2 surface anterior!• D2332 Resin 3 surface anterior!• D2335 Resin 4+ surface anterior!• D2391 Resin 1 surface posterior!• D2392 Resin 2 surface posterior!• D2393 Resin 3 surface posterior!• D2394 Resin 4+ surface posterior!• D3221 Pulpal debridement primary and perm!• D7111 Extract coronal remnants!• D7140 Extraction!• D7210 Surgical Extract/erupted!• D7220 Surgical Ext/impact/soft!• D7230 Surgical Ext/impact/part bony!• D7250 Surgical Ext/impact/full bony!• D9310 Consultation!• D9430 Office Visit/Observation!• D9440 Emergency office visit

SVT does not pay for drug/alcohol or mental

health referrals.

Jennifer Hayes"RDH

SVT HEALTH & WELLNESS

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AFFORDABLE CARE ACT

Under the Affordable Care Act every American must demonstrate health care coverage in the coming year. This means if you do not already have coverage (e.g., Medicaid, Medicare, Denali KidCare, VA Healthcare or private insurance) you will be required to purchase health insurance or face a penalty when filing your taxes. !!Alaska Native and American Indian people are exempt from the requirement to purchase insurance if they can show evidence of being enrolled in a federally recognized tribe. We recommend that you contact your village Tribe to determine how you can enroll. !!

Even with this exemption, Alaska Native and American Indian people may choose to purchase insurance. Alaskans will have a new option of purchasing health insurance through the federal marketplace. That’s where Emiley Sue Faris and Monica Anderson come in. Emiley and Monica are the Outreach Coordinators at SVT Health & Wellness in Homer.

- Our Patients’ Responsibilities -!• Arrive on time for appointments.!• Keep all scheduled appointments or call at least 24 hours in advance to reschedule or

cancel appointments. Call 226-2228 to make any appointment changes.!• Provide accurate and complete information regarding your health status.!• Share in health care decision-making and participate in the development of a

mutually agreed upon treatment plan with your health care provider.!• Maintain as healthy a lifestyle as possible and follow through with a treatment plan

you agree with.!• Treat other patients and staff with respect and courtesy.!• Ask questions about anything you do not understand.!• Let us know how we’re doing by filling out a patient satisfaction survey.!• Provide up-to-date contact information including the best way to reach you

Emiley Sue Faris"Patient Outreach Coordinator

SVT HEALTH & WELLNESS

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