The
Policies and Procedures
of
The Supplemental Dental Program
The policies and procedures for the Supplimental
Dental Plan, a department within the Health and Medical Division
of the Eastern Band of Cherokee Indians has been reviewed and approved
by:
- Jim Owle, Chairman, Health Board
- Susan Leading Fox, Deputy Director
- Jody Adams, HealthOperations
- Ann Bullock, Medical Director
Table of Contents
· Accompaniment of Minors
· Age Criteria for Orthodontic Services
· Alternate Resources-Check sent to Patients
· Alternate Resources
· Authority for Purchase Authorization
· Cancellation
· Contacting the Orthodontic Patient
· Contacting the Patient
· Deductibles or Co-Pays
· Dental Review Committee
· Did Not Keep Appointment
· Eligibility
· Follow-up Visits
· Orthodontic Purchase Authorizations
· Orthodontic Screening
· Orthodontic Services Covered
· Patient Selection Process
· Priority for Orthodontic Services
· Provider Selection
· Removal from Orthodontics Program
· Self Referring
· Service Procedure
· Transportation
· Unauthorized Services
Introduction
The Mental Health Center Policy and Procedure Manual is designed
to supplement the Eastern Band of Cherokee Indians Personnel Policy
Manual. The objective of this manual is to help facilitate the provision
of the utmost quality Mental Health care. It should also clarify
daily office activities and interactions with other departments
and professionals.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Accompaniment of Minors
PURPOSE: Define age in which children must be accompanied to medical
appointments.
STAFF GOVERNED BY THIS POLICY: Health Board, HMD staff, CIH Dental
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, HMD staff, CIH Dental
POLICY:
Every patient under the age of eighteen (18) must have a parent
or documented legal guardian accompany patient to the physician
and/or other health care provider office/facility for services.
Note: This is law for health care providers, so proper consent
forms for minors can be documented.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Alternate Resources-Check
sent to Patients
PURPOSE: Defines the policy for return of funds received from Alternate
Resources
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
The EBCI/HMD is payer of last resort. The EBCI/HM must pay the balance
of the bill if the Alternate Resource check goes to either the Health
Care Provider OR to the Patient
1) In the event that alternate resources are sent to the patient
or the patient’s guardian, the patient or guardian will be
responsible for reimbursing the Supplemental Dental Program.
2) The patient must give the check or equivalent to the Processing
Coordinator.
A. The Processing Coordinator will issue a triplicate pre-numbered
receipt to the patient or guardian, noting patient name, date of
service and date received.
B. The Processing Coordinator will deliver on a daily basis, an
accounting of all receipts received, along with the cash, check,
etc and a copy of the pre-numbered receipts, to the Medical Accounting
Office.
3) The Medical Accounting Office will prepare an income report and
deposit the receipts
with the Tribal Finance Office on a daily basis.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Alternate Resources
PURPOSE: Determines the role EBCI HMD will have if the patient has
alternate resources.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
1. The EBCI/HMD is payer of last resort. Patients eligible for alternate
resources must apply for dental services through the Health and
Medical Division.
2. If a patient possesses appropriate sources of primary health
care coverage, the HMD will only cover the patient’s “
individual liability” including co-pays and deductibles.
3. Patients must provide accurate alternate resource information
to the SDP staff. Failure to do so will result in disqualification
from receiving further services.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Cancellation
PURPOSE: Define the cancellation policy.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
1. The Case Coordinator must be notified 5 working days ahead of
scheduled appointment before another appointment will be made. The
Case Coordinator is responsible for cancellation and rescheduling
appointments.
2. If, at the last minute or less than 5 working days, a sudden
emergency occurs;
it must be immediate family death, or acute illness treated by an
MD or hospitalization (father, mother, brother, sister, husband,
wife), the Case Coordinator must be contacted so another appointment
will be scheduled as soon as possible.
3. If a broken appointment occurs the child may be removed from
the SDP.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Contacting the Patient
PURPOSE: Describes the process in making contact with the patient
and demonstrates reasonable diligence was applied.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
1. Referrals will be sent to HMD by CIH Dental Program.
2. Those patients meeting the criteria (scored to meet the eligibility,
must be an enrolled member of the EBCI).
3. Eligibility will be confirmed by checking the RPMS system and
Tribal enrollment. Patient will be notified by phone, if no contact
after 3 attempts patient will be sent a certified letter. This will
be the final attempt to contact an individual.
4. When contact is made with the patient, HMD will set up an appointment
for them.
5. When the appointment is set up the HMD will contact the patient,
inform then of the time and ask them to come by the office and pick
up a referral package and sign the Service Agreement.
Note : Documentation of letters sent will be recorded and kept on
file and shall serve as all the record Health & Medical needs
to discontinue its effort to locate a person.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Deductibles or Co-Pays
PURPOSE: Clarifies SDP’s policy on deductible and co-pays.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
1. If the patient has not met the deductible and/or co-pay, the
EBCI/HM will pay the deductible or co-pay when the alternate resource
is used.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Dental Review Committee
PURPOSE: Establishes a committee to review questionable cases of
misuse of the program.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff
POLICY:
HMD will establish a Dental Review Committee whose purpose is to
review misuse of the program and determine eligibility.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Did Not Keep Appointment
PURPOSE: Determines the process of dealing with patients who do
not keep appointments scheduled
under the Supplemental Dental Program.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 19, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
1. If a patients does not keep a scheduled appointment with a physician
or scheduled Health Care Service:
a. It will be reviewed for just cause by the Dental Review Committee.
b. If bill is incurred, it will be the responsibility if the patient/legal
designated parent or guardian to pay.
c. If life or death situations occur to prevent a patient from keeping
a scheduled appointment, the above will not occur. This includes
the death, acute illness or hospitalization of a spouse, child,
grandchild, husband, wife or parent.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Eligibility
PURPOSE: Determine eligibility for the SUPPLEMENTAL DENTAL PROGRAM..
STAFF GOVERNED BY THIS POLICY: Health Board, Health & Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health & Medical Staff
POLICY:
To be served through the SUPPLEMENTAL DENTAL PROGRAM patients must:
1) Be evaluated and referred by CIHA’s Dental Program.
2) Be an enrolled member of the Eastern Band of Cherokee Indians
Note: If you live outside the five (5) county contract service areas
and are an enrolled member of the Eastern Band of Cherokee Indians,
you are still eligible for service, however you must be referred
from CIH’s Dental Program.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Follow-up Visits
PURPOSE: Clarifies the extent of services provided after the initial
appointment.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical Staff
POLICY:
If having been referred by Health & Medical for SUPPLEMENTAL
DENTAL PROGRAM service and it is deemed by the physician/caregiver
the patient needs follow up service, the patient must go through
the Case Manage/system for the follow up visit to have the services
paid.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Age Criteria for Orthodontic
services
PURPOSE: Determine the appropriate age for eligibility of orthodontic
services.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
Children ages 10 to 17 will be eligible for orthodontic services.
Children 7-17 years of age will receive orthodontic screenings.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Authority for Purchase Authorization
PURPOSE: To ensure that purchase authorizations are issued only
when funds are available.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
Division
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov. 12, 2003
DISTRIBUTION: Children’s Dental Program, Health Board
POLICY:
No one shall have the authority to approve a purchase authorization
unless the necessary funds are available. These funds shall be used
for eligible patients requiring covered services, as established
by policy, and are subject to annual appropriations.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Contacting the Orthodontic Patient
PURPOSE: Define the procedure for contacting patients for orthodontic
services.
STAFF GOVERNED BY THIS POLICY: Children’s Dental Program
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Children’s Dental Program, Health Board
POLICY:
The Children’s Dental Program will provide advocacy and service
coordination in an efficient and diligent manner.
PROCEDURE:
1. The patient’s parent or caregiver, will be notified by
the Health and Medical Division within 20 days of
receiving the screening tool from the Dental staff.
2. The patient/parent will be notified by phone or mail if the child
is to be served.
3. If the child is not eligible for services the parent will receive
notification, which will include a
statement from HMD Children’s Dental Program that can be taken
to Finance for further action.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Priority for Orthodontic Services
PURPOSE: Define the priorities for serving children under 18 who
need orthodontic services.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
Priority will be given to orthodontic patients in the following
order:
1. Malocclusions that affect “function”.
2. Malocclusions that have no long term functional impact.
3. Severe esthetic conditions that have psychosocial implications.
4. Moderate esthetic conditions that have psychosocial implications.
5. Mild esthetic conditions that have psychosocial implications.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Orthodontic Purchase Authorizations
PURPOSE: Define the personnel charged with coordinating services
for orthodontic patients.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
Coordinating services is a multidisciplinary function. This policy
attempts to clarify the responsibilities and authority of each.
Under no circumstances will the EBCI pay for services that are not
coordinated in compliance with the procedures below.
PROCEDURE:
1. No person shall have the authority to determine the need for
services other than a IHS or EBCI dentist.
2. The Case Manager, in accordance with Ordinance 470, shall determine
eligibility for participation in the
program.
3. The Case Manager shall, based on eligibility and identification
of need, approve a purchase authorization
for the needed service.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Removal from Orthodontics Program
PURPOSE: Determines criteria for removal from Orthodontics Program
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
If for any reason the Orthodontist determines treatment of the patient
will not continue (missing appointments, inappropriate care, etc.)
the patient will not be eligible for services for a minimum of two
years.
PROCEDURE:
1. If the Orthodontist makes a decision to discontinue treatment
he will notify the parents, or caregiver and
the Case Manager.
2. In accordance with the Orthodontic Service Agreement, the Case
Manager will notify the parents or
caregiver and a time of re-entry will be established.
3. A Copy of the re-entry notification letter will be placed in
the patient file until the completion of the 2
year period.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Orthodontic Screening
PURPOSE: Establish policy for screening of orthodontic patients.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
1. All participants in the Orthodontic section of the Children’s
Dental Program must be screened at Cherokee Indian Hospital using
the Orthodontic Screening form and must be an Eastern Band of Cherokee
Indians enrolled member.
2. Orthodontic Screening does not guarantee participation in the
CDP-O.
3. Within 5 working days the screening will be rated and referrals,
if necessary, will be made.
PROCEDURE:
1. Call Cherokee Indian Hospital and request an Orthodontic Screening.
2. Comply with the appointment for screening as scheduled.
3. Dentist will perform screening and complete screening tool.
4. Screening tool results will be batched and communicated with
the Case Manager weekly.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Orthodontic Services Covered
PURPOSE: Established a system for allocating resources to a greatest
area of need.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: March 1, 2002
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff, CIH Dental
Staff
POLICY:
Whereas the resources available for this program are insufficient
to address all of the orthodontic needs for the children of this
community and until sufficient resources are available, it is the
policy of this program to adopt an objective screening tool to identify
the service needs of the community. The tool adopted is included
as an attachment to this policy.
PROCEDURE:
1. Upon completion of screening, the appropriate dentist will establish
a numerical score utilizing the
approved screening tool.
2. A copy of said tool will be forwarded to the appropriate Case
Manager.
3. Until adequate funding is available, and the authority to do
so is given, patients with scores of less than
30 will not be approved.
4. For those patients who score is equal to or greater than 30,
the Case Manager shall have the authority to
approve all services as long as funding is available.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Patient Selection Process
PURPOSE: Determine how patients are selected for the SUPPLEMENTAL
DENTAL PROGRAM.
STAFF GOVERNED BY THIS POLICY: HMD staff, Health Board
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health & Medical staff
POLICY:
1. The Cherokee Indian Hospital Dental Program will select children
to be served on this project.
2. The names of patients needing dental services will be sent to
the SDP Coordinator.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Provider Selection
PURPOSE: Establish the party responsible for selection of providers.
STAFF GOVERNED BY THIS POLICY: HMD staff, Health Board
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: HMD staff, Health Board
POLICY:
The Provider (physician, hospital, other health care providers)
shall be the decision of the EBCI/Health & Medical Division
only based on contractual agreements.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Self Referring
PURPOSE: Discourage patients who seek funding or reimbursement after
self referral.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff
POLICY:
The Health and Medical Division WILL NOT PAY or reimburse patients
who self-refer themselves for dental services. This means if a patient
goes outside of the Health & Medical Division for dental services,
the HMD cannot and will not pay for these services.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Service Procedure
PURPOSE: Defines the steps in dental services.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff
PROCEDURE:
1. The patient will see the dentist for an assessment.
2. The patient will see a Pediatrician for a physical exam. (Asheville
Pediatrics, or Asheville Children’s Medical Center)
3. The patient will be scheduled for surgery at Mission Saint Josephs.
4. The patient will receive a follow-up visit at CIH Dental Clinic.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Transportation
PURPOSE: Establish parameters of transportation.
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff
POLICY:
The Health & Medical does not provide transportation for any
SDP patient. The EBCI Transit System operated by the Tribe does
provide such. HMD will assist patients in contacting the tribal
Transit System.
Health and Medical Division
Supplemental Dental Program
SUBJECT: Unauthorized Services
PURPOSE: Establish parameters of services
STAFF GOVERNED BY THIS POLICY: Health Board, Health and Medical
staff
EFFECTIVE DATE: July 18, 2001
DATE REVIEWED OR REVISED: Nov 12, 2003
DISTRIBUTION: Health Board, Health and Medical staff
POLICY:
The EBCI Health and Medical Division will not expend monies for
health care services other than what they are referred or authorized
for in the original SUPPLEMENTAL DENTAL PROGRAM referral.
|
