Eligibility For Services
The Round Valley Indian Health Center (RVIHC) is a small ambulatory out-patient state licensed community health clinic. RVIHC is also a 501(c)(3) non-profit state corporation that provides health care services to the entire community of Round Valley. The primary funding source of RVIHC is the Indian Health Service (IHS); however, due to insufficient funding the health center bills third party health insurances and has available program for patients with limited resources as outlined below. Below is a list of third party resources pertaining to direct care and onsite services.
The Health Center also has contracted health care funds for eligible Native American patients for hospital and specialty care. The requirement for contracted health care is described below; see Contract Health Services (CHS).
Third Party Resources
Medi-Cal patients are accepted for all services offered at the Health Center.
Medi-Care patients are accepted for all services offered at the Health Center.
The Health Center will bill private insurance companies. The co-pay is due at the time of the visit.
Fee for service Patients are those with no insurance coverage who are not eligible for the discount programs offered by the Health Center are expected to pay at the time of service.
Contract Health Services
The following eligibility information is for receiving Contract Health Services (CHS) services that are not provided at the Health Center. Please note, the Health Center cannot always guarantee that sufficient funds will be available for all patient's health care needs, therefore the Health Center is mandated by the Indian Health Service to use the eligibility criteria and payment process described below.
Contract Health Services Eligibility Criteria
Prior to a request for CHS services an individual must:
Provide documentation that you are an American Indian from a tribe that is native to California or a non-California Indian from a federally recognized tribe.
Have established residency in the Round Valley CHS delivery area (CHSDA) for six (6) months.
Must obtain a level one CHS referral from a Round Valley Indian Health Center provider for each outside appointment.
Have applied for every alternate resource for which they may be eligible, such as Medi-Cal, Medi-Care, CMSP or private insurance. This is a federal requirement, since the Indian Health Service is a payor of last resort.
You must notify the CHS office with 72 hours of any medical emergency. All services reported within 72 hours are not guaranteed payment, unless the diagnosis falls within the level one criteria.
Referrral Process
Prior authorization is required for all medical services and follow-up care. A provider referral does not constitute any commitment by the Round Valley Indian Health Center to pay for any services. Only authorized health center personnel can approve payment for care outside the Health Center facility.
Medical providers at Round Valley Indian Health Center determine patients' medical diagnosis. That diagnosis will fall into one of five (5) levels of care determined by the CHS Federal Guidelines. The RVIHC Board of Directors determines which level(s) of care will be paid for by the Health Center. Due to insufficient funding by the Indian Health Service, only level one (life threatening, see list below) diagnoses are paid for by the Health Center. For at least the last ten (10) years the Health Center has supplemented our CHS budget by 250 percent with third party revenues to insure that our people get adequate hospital and specialty care. We feel this a good use of Health Center revenue because we are paying for health care for our community members.
The following situations qualify as Acute Emergency/Urgent Care (level one) services:
Acute trauma/motor vehicle accidents
Acute lacerations
Acute mental status changes
Acute bleeding
Acute shortness of breath
Acute chest pain
Acute abdominal pain
Acute burns over greater than five percent of body surface
Seizures
Acute dental pain/surgery
Functional impairment
Loss of eye sight or limb(s)
Principle Reasons for Denial of CHS Payment
Does not fit eligibility criteria described above.
Patient fails to obtain approval for a non-emergency service.
Having Medi-Cal at time of visit and not giving the information to the provider. The bill will be your responsibility.
Failure to keep up status reports to Medi-Cal for continued medical coverage.
The patient's failure to notify the CHS office within 72 hours of an emergency.
Not applying for an alternate resource and following through to determine eligibility.
Denied by Medi-Cal for an invalid reason.
The patient is referred to an outside provider on a non-level one referral.
Referred to an outside provider by someone other than a Round Valley Indian Health Center provider.
Alternate Resources
CHS payment will not be made unless a patient has exhausted all other avenues of obtaining an alternate resource. Applications to apply for Medi-Cal will be offered at the time of registration. A patient is required to bring income verification for determination of Medi-Cal eligibility. If your income exceeds the poverty guidelines of Mendocino County, you will not be required to complete a Medi-Cal application. Adults that exceed the poverty guidelines may be eligible for County Medi-Cal (CMSP), with a share of the cost and will be asked to apply. A valid denial will be required as with State Medi-Cal. If the patient refuses to bring in income and residency verification for screening, the patient will not be eligible for CHS.
Appeals Process
If a person is denied CHS payment for care, the CHS office will issue a denial letter. The letter of denial of payment shall explain the rights of appeal. The patient being denied has 30 days from receipt of the letter to appeal to:
Executive Director, Round Valley Indian Health Center
P.O. Box 247,
Covelo, CA 95428
If the decision to deny is upheld by the Executive Director, the patient may then appeal to:
CHS Committee
P.O. Box 247
Covelo, CA 95428
The decision of the CHS Committee shall constitute a final administrative action. CHS will not pay for services or supplies that are not necessary for the diagnosis and treatment of a covered illness or injury.
If you do not have medical coverage,
please contact the following staff to assist you:
Niquita Whitehurst Admin office 707-983-6404 ext. 121