Emergent/Acutely Urgent Care Services

Definition: Diagnostic or therapeutic services that are necessary to prevent the immediate death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible health care available and capable of furnishing such services. Diagnosis and treatment of injuries or medical conditions that, if left untreated, would result in uncertain but potentially grave outcomes.

Categories of Services Included:

  • Emergency room care for emergent/urgent medical conditions, surgical conditions, or acute trauma
  • Emergency inpatient care for emergent/urgent medical conditions, surgical conditions, or acute injury
  • Renal replacement therapy, acute or chronic
  • Emergency psychiatric care involving suicidal persons or those who are a serious threat to themselves or others
  • Services and procedures necessary for the evaluation of potentially life threatening illnesses or conditions
  • Obstetrical deliveries and acute perinatal care
  • Neonatal care

See appendix 1 for examples of specific diagnoses

Preventive Care Services

Definition: Primary health care that is aimed at the prevention of disease or disability. This includes services proven effective in avoiding the occurrence of a disease (primary prevention) and services proven effective in mitigating the consequences of an illness or condition (secondary prevention)

Categories of Services Included: 

  • Routine prenatal care
  • Non-urgent preventive ambulatory care (primary prevention)
  • Screening for know disease entities (secondary prevention)
  • Screening Mammograms 
  • Public health intervention

The IHS requires a high priority for preventative health care services. Level II services are distinguished from emergency care, sophisticated diagnostic procedures, treatment of acute conditions, and care primarily intended for symptomatic relief or chronic maintenance.

Most services listed as Level II are available at IHS direct care facilities. When these services are purchased using PRC funding, it is usually requested by an IHS or tribal service unit with no direct care capabilities. In addition; IHS direct care facilities may, at times, find it necessary to purchase or defer these types of services, if they are unable to directly provide for any of their patient's preventative health care needs.

Elective Referrals Initiated by IHS Providers

When patients are referred for elective procedures, consultation, outpatient or inpatient care, payments for eligible patients should be authorized only when the care required is medically necessary and falls within established medical priorities. All referrals will be reviewed and approved in a prescribed manner.

The condition of the patient at the time of referral will influence the ultimate determination of Level III and IV services. In order to determine whether or not the needed care is within established medical priorities the following questions should be considered:

  • What is the rate of deterioration of the patient's condition (is the needed service deferrable or non-deferrable)?
  • What will be the potential morbidity on the patient if the desired care is not rendered (are there any uncertain but potentially grave outcomes)?
  • What is the expected benefit from the evaluation or treatment (will the care likely result in a cure or improvement)?
  • Is the procedure experimental or purely cosmetic (is the requested service on the excluded list)?

In general, authorization will be made for only one visit at a time, or for a prescribed number of visits. If additional procedures or care are required, the medical priority of the follow-up request may be different. Patients will be asked to return for another referral.

Primary and Secondary Care Services

Definition: Inpatient and outpatient care services that involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity or mortality. This involves treatment for conditions that may be delayed without progressive loss of function or risk of life, limb, or senses. It includes services that may not be available at many IHS facilities and/or may require specialty consultation.

Categories of Services Included:

  • Scheduled ambulatory services for non-emergent conditions
  • Speciality consultations in surgery, medicine, obstetrics, gynecology, pediatrics, ophthalmology, ENT, orthopedics, and dermatology
  • Elective, routine surgeries that have a significant impact on morbidity and mortality
  • Diagnostic evaluations for non-acute conditions
  • Specialized medications not available at an IHS facility, when no suitable alternative exists

Chronic Tertiary and Extended Care Services

Definition: Inpatient and outpatient services that (1) are not essential for initial/emergent diagnosis or therapy, (2) have less impact on mortality than morbidity, or (3) are high cost, are elective, and often require tertiary care facilities. These services are not readily available from direct care IHS facilities. Careful case management by the Medical Care Review Committee is a requirement. 

Categories of Services Included:

  • Rehabilitation care
  • Skilled nursing facility (medicare defined)
  • Highly specialized medical services/procedures
  • Other specialized elective surgery such as obesity surgery
  • Elective open cardiac surgery
  • Organ transplantation (HCFA approved organs only)

Traditional Native American healing practices

According to IHS policy on traditional healing and religious practices, "when an IHS patient requests assistance in obtaining the services of a native practitioner, every effort will be made to comply. Such efforts might include contacting a native practitioner, providing space and privacy within a hospital room for a ceremony, and/or the authorization of contract health care funds to pay for native healer consultation." For medical priority purposes, these native practitioner services will be equivalent to Level IV services.

Excluded Services

Definition: Services and procedures that are considered purely cosmetic in nature, experimental or investigational, or have no proven medical benefit.

V.A. Cosmetic Procedures-Payment for certain cosmetic procedures may be authorized if these services are necessary for proper mechanical function or psychological reasons.  

V.B. Experimental and Other Excluded Services-Payment is not authorized. 

The list of therapies and procedures classified as potentially cosmetic in nature, experimental, or excluded will be reviewed and updated on an annual basis.

Categories of Excluded Services:

  • All purely cosmetic (not reconstructive) plastic surgery
  • Procedures defined as experimental by the Health Care Financing Administration
  • Procedures for which there is no proven medical benefit-procedures listed as "Not Covered" in the Medicare Coverage Issuance Manual, Section 27,200
  • Extended care nursing homes (intermediate or custodial care)
  • Alternate medical practices (e.g., homeopathy, acupuncture, chemical endarterectomy, natureopathy)