Appeal Process

Purchased/Referred Care (PRC) funds are used to supplement and complement other health care resources available to eligible Indian people. However, Purchased/Referred Care may be denied for eligibility, notification requirements, medical priorities of care, and use of alternate resources.

If a person is denied PRC, or when a medical provider may reasonably think that IHS is a party to payment, both the patient and the provider must be notified in writing of the denial with a statement containing all the reasons for the denial. A person denied PRC may request a reconsideration of the denial. Below is an excerpt regarding appeals from 42 CFR; this excerpt will provide information on the appeals process.

Tribal Health facilities may differ in some aspects of the appeal process; please contact the tribal health facility in your area for more information.

From the Federal Register, 10-01-2017 edition). Part VIII, Department of Health and Human Services. 42 CFR Parts 136 - Indian Health, Subpart C - Contract Health Services:

♦ 136.25 Reconsideration and appeals.

1. Any person to whom contract health services are denied shall be notified of the denial in writing together with a statement of the reason for the denial. The notice shall advise the applicant for contract health services that within 30 days from the receipt of the notice the applicant:
   1. May obtain a reconsideration by the appropriate Service Unit Director of the original denial if the applicant submits additional supporting information not previously submitted; or
   2. If no additional information is submitted, may appeal the original denial by the Service Unit Director to the appropriate Area or program director. A request for reconsideration or appeal shall be in writing and shall set forth the grounds supporting the request or appeal.
2. If the original decision is affirmed on reconsideration, the applicant shall be so notified in writing and advised that an appeal may be taken to the Area or program director within 30 days of receipt of the notice of the reconsidered decision. The appeal shall be in writing and shall set forth the grounds supporting the appeal.
3. If the original or reconsidered decision is affirmed on appeal by the Area or program director, the applicant shall be so notified in writing and advised that a further appeal may be taken to the Director, Indian Health Service, within 30 days of receipt of the notice. The appeal shall be in writing and shall set the grounds supporting the appeal. The decision of the Director, Indian Health Service, shall constitute final administrative action.