Coverage type · Military, veteran or federal employee
Indian Health Service Purchased/Referred Care
Indian Health Service money for care from outside providers. It is not an entitlement, and a referral does not mean the bill will be paid. Each of the three appeal steps has a 30-day deadline from receiving the notice.
On this page 7
- Who has this
- People who receive care from outside providers that the Indian Health Service refers them to and may pay for through its Purchased/Referred Care program, which the regulation calls contract health services.
- Who regulates it
- The Indian Health Service, part of the federal government. The rules are in Title 42 of the Code of Federal Regulations, sections 136.23 to 136.25.
- Can your state help?
- No. The appeal steps are federal and run through the Indian Health Service. No state agency is part of them. Find your state.
How to tell this is your coverage
- Your denial comes from the Purchased/Referred Care program in writing, with the reason, and explains that you can ask for reconsideration or appeal within 30 days of receiving it.
- If a tribe runs your health program, the appeal process may differ in some ways. Ask your tribal health facility.
The appeal steps, in order
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Ask for reconsideration
Official name: Reconsideration by the Service Unit Director
- Who decides
- The Service Unit Director. If you have no new supporting information, you can skip to the next level and appeal directly to the Area or program director.
- Your deadline
- 30 days after you receive the denial notice. Your request must be in writing and state your grounds. Check the date on your notice, which controls.
- Their deadline
- The rules we use do not state a decision deadline at this level. Ask in writing for the date.
- What to send
- A written request that states the grounds, with any new information that supports your claim, such as your doctor's letter, proof you told the program about emergency care in time, or proof of other coverage.
- If you lose, or hear nothing
- If the denial is upheld on reconsideration, you have 30 days from receiving that notice to appeal to the Area or program director.
- The rule
- 42 CFR 136.25, appeals
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Appeal to the Area or program director
- Who decides
- The Area or program director of the Indian Health Service
- Your deadline
- 30 days after you receive the notice that upheld the denial on reconsideration. If you had no new information, 30 days after you received the original denial notice. Check the date on your notice, which controls.
- Their deadline
- The rules we use do not state a decision deadline at this level. Ask in writing for the date.
- What to send
- A written appeal that states your grounds and attaches the earlier decisions.
- If you lose, or hear nothing
- If the Area or program director upholds the denial, you have 30 days to appeal to the Director of the Indian Health Service.
- The rule
- 42 CFR 136.25, appeals
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Final appeal
Official name: Appeal to the Director of the Indian Health Service
- Who decides
- The Director of the Indian Health Service. This decision is the final administrative action.
- Your deadline
- 30 days after you receive the Area or program director's decision. Check the date on your notice, which controls.
- Their deadline
- The rules we use do not state a decision deadline at this level.
- What to send
- A written appeal with the earlier decisions and your grounds.
- If you lose, or hear nothing
- This is the last administrative level. Ask free legal aid what else, if anything, is available.
- The rule
- 42 CFR 136.25, appeals
If waiting could harm your health
The program is not an entitlement, and an Indian Health Service referral does not mean the care will be paid. Notify the program within 72 hours of emergency treatment or admission. The Indian Health Service page gives 30 days for elderly or disabled persons under section 406 of Public Law 94-437; we did not open that law. Missing notification is a common reason for denial, and you can address it on appeal. Check the date on your notice, which controls.
Free help for this coverage
- Indian Health Service Purchased/Referred Care appeal process
The Indian Health Service describes each appeal step on its page.
- Your tribal health facility
If a tribe runs your health program, ask the facility how its appeal process works.
- Legal aid
Free civil legal help for people with low incomes. A program can advise you on an appeal, but it cannot take every case. Your state page lists legal aid programs for your state.
Who this covers
This page is for people whose care by an outside provider, arranged through the Indian Health Service, was denied payment by its Purchased/Referred Care program. If you are also covered by Medicare, Medicaid or private insurance, see Original Medicare, Medicaid or use the coverage type finder.
How to tell this is your coverage
Purchased/Referred Care pays for care from providers outside the Indian Health Service. Payment depends on residency, notification, medical priority and use of other resources. A denial must be in writing, give the reason, and explain the 30-day appeal steps.
What does not apply to you
This is not health insurance that pays every covered claim. It is not an entitlement. The Director of the Indian Health Service makes the final administrative decision. Tribally operated programs may differ in some aspects of the appeal process. The Medicare appeal levels and Medicaid fair hearings do not apply to a Purchased/Referred Care decision.
Where people go wrong
- Assuming a referral means payment. A referral does not mean the care will be paid.
- Missing the notification. A common denial reason is that the program was not notified within 72 hours of emergency treatment or admission. Appeal quickly and explain what happened.
- Ignoring other coverage. The Indian Health Service is the payer of last resort after Medicare, Medicaid, private insurance and other alternate resources. If another payer is available, that can be a reason for denial.
- Letting a 30-day clock lapse at any of the three steps. Each step has its own 30-day deadline from the notice for that step.
- Missing medical priority rules. When funds are limited, the care must be within medical priorities. This can be a reason for denial that you can address on appeal.
Free help is listed above.
Sources
- Indian Health Service, Purchased/Referred Care
- Indian Health Service, Purchased/Referred Care appeal process
- Indian Health Service, notification requirements
- 42 CFR 136.23, contract health services eligibility and alternate resources
- 42 CFR 136.24, notification
- 42 CFR 136.25, appeals
- 42 CFR 136.61, payer of last resort