Referrals, Denials and Appeals - Yellowhawk Tribal Health Center
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Referrals, Denials and Appeals

Referral Process

Most referrals are initiated when you are seen by a Yellowhawk provider (Doctor, Dentist, Nurse Practitioner, Counselor) and they determine that you need a service not provided at our facility. In such instances they will issue a referral, help you obtain preauthorization for payment, and arrange for you to be seen by the outside provider that you are being referred to.

 

When referrals are initiated by outside providers or when you have additional visits or tests, the patient has the responsibility to submit the referral information to the Patient Care Coordinators to request preauthorization of payment. Once the preauthorization is obtained, a Patient Care Coordinator will assist you in setting up the appointment
with the provider to whom you are being referred.

 

Before your appointment be sure the outside provider has received a pre-authorization from Yellowhawk.

 

If you are unable to keep an appointment or need to re-schedule, please notify your Patient Care Coordinator as soon as possible, prior to your scheduled appointment. Please keep in mind, patients are responsible for any charges incurred with missed appointments.

 

If you have any further questions regarding the referral process, please contact your Patient Care Coordinator.

Denials

If payment for a medical bill is denied, you will be notified by Yellowhawk. The most common reasons for denial are:

 

  • Ineligibility because of failure to prove you are of American Indian/Alaska Native descent
  • Ineligibility because you do not reside within the Yellowhawk Service Area
  • Refusal to apply for and/or use alternative insurance
  • Visited an Emergency Room (ER) or Urgent Care for non-emergent services; did not notify Yellowhawk within 72 hours of ER visit; or did not follow-up with healthcare provider as requested after ER visit
  • Failure to provide required documents to Yellowhawk (i.e. proof of insurance or other documents)
  • Failure to get preauthorization for services to an outside provider and/or facility

Appeals

If you would like to appeal a payment denial you must provide a written response to the Yellowhawk Resource Management Committee (RMC) within 30 days of the date of the denial letter. Your appeal should identify the reasons you believe the healthcare visit should be paid for and any circumstances you believe should be considered as relevant. Yellowhawk Purchased Referred Care (PRC) staff are available to assist patients in writing letters of appeal. All relevant supporting documentation should also be included in the letter. Yellowhawk’s Resource Management Committee will review this information at the next scheduled meeting. If additional

information is needed, the patient will be contacted. This committee typically meets twice a month.

 

When the RMC upholds the original denial, the patient has thirty (30) days in which to appeal the decision by providing a written request to the Yellowhawk Executive Assistant for logging and tracking. The executive assistant will immediately forward this on to the Yellowhawk Chief Executive Officer (CEO). This statement should include the reasons why the patient believes the referral should be issued or payment should be made and any relevant supporting information or documentation.

 

The Yellowhawk CEO will review all of the supporting documentation and issue a decision on whether to uphold the denial or issue a referral or payment. The CEO will respond to the patient’s appeal in writing, listing the reason for their decision within ten (10) business days. The PRC Resource Management Committee representative will be provided a copy of the decision.

 

If the CEO’s decision is to support the original denial, the patient may make an additional appeal to the Portland Area Indian Health Service (IHS) within 30 days of the Yellowhawk CEO’s denial letter. Again, the appeal shall be in writing and must contain all supporting documentation pertaining to the case. The decision of the Portland Area IHS is final and cannot be appealed.