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Brief Overview

I. Medical Priority Level I – Emergent or Acutely Urgent Care Services

  1. Emergent or Acutely Urgent Care Services are 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.

II. Medical Priority Level II – Preventive Services

  1. Preventive 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 Priority Level II are available at IHS direct care facilities. If no direct care capabilities are available at the IHS or Tribal direct care facility, preventative services can be purchased using PRC funds

III. Medical Priority Level III – Primary and Secondary Care Services.

  1. Primary and Secondary Care Services include inpatient and outpatient care services. The inpatient and outpatient services involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity and mortality. This involves treatment for conditions that may be delayed without progressive loss of function or risk of life, limb, or senses. It also includes services that may not be available at Tribal and IHS facilities and/or may require specialty consultation.

IV. Priority Level IV – Chronic Tertiary and Extended Care Services.

  1. Chronic Tertiary and Extended Care Services are 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 or Tribal facilities.

V. Medical Priority Level V – Excluded Services.

  1. Excluded Services includes cosmetic procedures, experimental and other procedures excluded from authorization for PRC payment. The list of Medical Priority Level V-Excluded Services is based upon the Centers for Medicare and Medicaid’s (CMS) Medicare National Coverage Determinations Manual.
    1. Procedures. The Fiscal Intermediary (FI) will not pay a claim for a potentially cosmetic procedure listed in Medical Priority Level V-Excluded Services, Exceptions may be granted if one of the listed procedures, normally considered cosmetic, is necessary for proper mechanical function or psychological reasons.
    2. Experimental and other Excluded Procedures. Payment for the excluded procedures listed in Medical Priority Level V-Excluded Services will not be paid.
    3. Payment for Direct Services. Examples of direct care services that cannot be reimbursed with PRC funds are on-call hours, after hours or weekend pay, holiday coverage (e.g., for x-ray, laboratory, pharmacy).

Through Overview of PRC Medical Priority Levels

I. Medical Priority Level I – Emergent or Acutely Urgent Care Services

  1. Definition. Emergent or acutely urgent care services are 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 emergent or acutely urgent care services include (random order):
    1. Emergency room care for emergent or urgent medical conditions, surgical conditions, or acute trauma.
    2. Emergency inpatient care for emergent or urgent medical conditions, surgical conditions, or acute injury.
    3. Acute and chronic renal replacement therapy.
    4. Emergency psychiatric care involving suicidal persons or those who are a serious threat to themselves or others.
    5. Services and procedures necessary for the evaluation of potentially life threatening illness or conditions.
    6. Obstetrical deliveries and acute perinatal care.
    7. Neonatal care
  2. Medical Priority Level I -Diagnosis. Examples of diagnosis that usually require emergent/acutely urgent care services include but are not limited to:
    1. Musculoskeletal trauma acute
    2. Cancer Chemotherapy
    3. Cholecystitis, acute
    4. Coma
    5. Concussion
    6. Congestive heart failure, decompensated
    7. Pancreatitis
    8. Dehydration, severe
    9. Delirium tremens
    10. Diabetic ketoacidosis
    11. Drowning, near
    12. Embolism, cerebral or peripheral
    13. Encephalitis
    14. Epididymitis, acute
    15. Epiglottitis
    16. Eye disease, acute
    17. Flail chest
    18. Fractures
    19. Glomerulonephritis
    20. Gunshot wounds
    21. Head injury
    22. Heat exhaustion and prostration
    23. Hemoptysis
    24. Hemorrhage
    25. Hepatic encephalopathy
    26. Myocardial infractions
    27. Myocardial ischemia, acute
    28. Obstetrical emergencies
    29. Pelvic inflammatory disease
    30. Peritonitis
    31. Pneumonia, acute
    32. Pneumothorax
    33. Poisoning
    34. Premature infant
    35. Pulmonary embolism
    36. Pulmonary edema
    37. Puncture or stab wounds
    38. Radiation Therapy
    39. Rape, alleged, examination
    40. Renal lithisasis, acute
    41. Renal failure, acute
    42. Respiratory failure
    43. Sepsis
    44. Shock
    45. Spinal column injuries
    46. Suicide attempt
    47. Urinary retention, obstruction

II. Medical Priority Level II – Preventive Care Services

  1. Definition. Preventive care services are available at most IHS facilities. Preventive care service is 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 (random order):
    1. Routine prenatal care
    2. Non-urgent preventative ambulatory care (primary prevention)
    3. Screening for known disease entities (secondary prevention)
    4. Screening Mammograms
    5. Public health intervention
  2. Medical Priority Level II – Examples. Examples of procedures or services that are usually considered preventive care services include but are not limited to:
    1. Audiology screening
    2. Diabetes maintenance
    3. Hemophilus prophylaxis
    4. HIV testing
    5. Immunizations
    6. Mammography
    7. Periodic health exams of infants, children, and adults
    8. Podiatry care for diabetics
    9. Sexually transmitted diseases, testing and treatment
    10. Vision examinations
    11. Cancer screening
    12. Family planning services
    13. Hepatitis prophylaxis
    14. Hypertensive screening, diagnosis, and control
    15. Laboratory services supporting primary care evaluations
    16. Meningitis prophylaxis
    17. Pregnancy and infant care
    18. Routine PAP smears/Colposcopy
    19. Tuberculosis screening, prophylaxis, and treatment
    20. X-ray services supporting primary care evaluations

III. Medical Priority Level III – Primary and Secondary Care Services

  1. Definition. Primary and Secondary Care Services include inpatient and outpatient care services. The inpatient and outpatient services involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity and mortality. This involves treatment for conditions that may be delayed without progressive loss of function or risk of life, limb, or senses. It also includes services that may not be available at many IHS facilities and/or may require specialty consultation. Categories of services included (random order):
    1. Scheduled ambulatory services for non-emergent conditions.
    2.  Specialty consultations in surgery, medicine, obstetrics, gynecology, pediatrics, ophthalmology, ENT, orthopedics, and dermatology.
    3. Elective, routine surgeries that have a significant impact on morbidity and mortality.
    4. Diagnostic evaluations for non-acute conditions.
    5. Specialized medications not available at an IHS facility, when no suitable alternative exists.
  2. Medical Priority Level III – Examples. Procedures or referrals that usually are considered Primary and Secondary Care Services included but are not limited to:
    1. Arthroscopy
    2. Bladder suspension
    3. Cardiac catheterization
    4. Cardiology referral (non-acute)
    5. Cholecystectomy
    6. CT Scan/MRI
    7. Dermatology
    8. Electroencephalogram
    9. Electronystagmogram
    10. Endocrinology
    11. Exercise stress testing
    12. Eye glasses refractions
    13. Gastroscopy
    14. Gynecology
    15. Hearing aids
    16. Hematology referral
    17. Hemorrhoidectomy
    18. Hemiorrhaphy
    19. Hysterectomy
    20. Lumbar laminectomy
    21. Nephrology/urology referral
    22. Neurology evaluations (elective)
    23. Nuclear medicine
    24. Orthotics
    25. Ophthalmology
    26. Podiatry, non-diabetic
    27. Prosthetics
    28. Psychiatric evaluations
    29. Pulmonary referral
    30. Pulmonary function testing
    31. Rheumatology
    32. Surgery referral, elective
    33. Tonsillectomy
    34. Tympanoplasty

IV. Medical Priority Level IV – Chronic Tertiary and Extended Care Services

  1. Definition. Chronic Tertiary and Extended Care Services are 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 service unit CHS committee is a requirement, as is monitoring by the Area CMO or his/her designee. Depending on cost, the referral may require concurrence by the CMO. Categories of services included (random order):
    1. Rehabilitation care
    2. Skilled nursing facility (Medicare defined)
    3. Highly specialized medical services/procedures
    4. Restorative orthopedic and plastic surgery
    5. Other specialized elective surgery such as obesity surgery
    6. Elective open cardiac surgery
    7. Organ transplantation (CMS approved organs only)
  2. Medical Priority Level IV – Examples. Diagnosis or procedures that usually are considered Medical Priority Level IV -Chronic Tertiary and Extended Care Services included but are not limited to:
    1. Angiocardiography
    2. Coronary bypass (non-acute)
    3. Facial bone repair
    4. Immunotherapy
    5. Lithotripsy
    6. Neurosurgery
    7. Pain control programs
    8. Plasmapheresis
    9. Portable fusion pumps
    10. Radical neck surgery
    11. Rhytidectomy
    12. Valvular open-heart surgery
    13. BCG vaccine (as adjuvant therapy for cancer)
    14. Esophageal pH monitoring
    15. Gastric bypass surgery
    16. Joint replacement
    17. Mammoplasty, reconstructive
    18. Osteoplasty (osteotomy)
    19. Passive motion exercise devices
    20. Plastic surgery, reconstructive
    21. Porta-caval shunt
    22. Rhinoplasty
    23. Sympathectomy

V. Medical Priority Level V – Excluded Services

  1. Definition. Excluded services are services and procedures that are considered purely cosmetic in nature, experimental or investigational, or have no proven medical benefit. The list of therapies and procedures classified as potentially cosmetic in nature, experimental, or excluded will be reviewed and updated on an annual basis.
  2. Excluded Services – Categories. Categories of excluded services include:
    1. All purely cosmetic (not reconstructive) plastic surgery;
    2. Procedures defined as experimental by the Centers for Medicare and Medicaid Services;
    3. Procedures for which there is no proven medical benefit procedures listed as “Not Covered” in the CMS Medicare National Coverage Determinations Manual;
    4.  Extended care nursing homes (intermediate or custodial care); and
    5. Alternate medical practices (e.g., homeopathy, acupuncture, chemical endarterectomy, naturopathy.)
  3. Cosmetic Procedures. Payment for certain cosmetic procedures may be authorized if these services are necessary for proper mechanical function or psychological reasons. Approval from the Area CMO is required.
  4. Experimental and other Excluded Services Procedures. Payment for Experimental and Other Excluded Services is not authorized, unless a formal exception is granted by the IHS CMO.
  5. Medical Priority Level V – Examples.
    1. Cosmetic. Examples of cosmetic services that are considered either experimental or excluded. (Not an all-inclusive list.)
      1. Argon Laser Treatment for Congenital Hemangiomas
      2. Topical Chemotherapy (Total Face and/or Neck)
      3. Mastectomy for Gynecomastia
      4. Mastectomy, Subcutaneous with Delayed Prosthetic Implant
      5. Removal of Mammary Implant Material
      6. Reconstruction of Nipple and/or Areola
      7. Revision (Release of Scar Contracture) of Breast, following Mammoplasty
      8. Blepharoptosis Repair
      9. Tattooing
      10. Subcutaneous Injection of “Filling” Material (i.e., Collagen)
      11. Insertion of Tissue Expanders
      12. Dermabrasion
      13. Abrasion (i.e., Keratoses)
      14. Chemical Peell
      15. Salabrasion
      16. Cervicoplasty
      17. Rhytidectomy
      18. Excision Excessive Skin and Subcutaneous Tissue (Including Lipectomy)
      19. Suction Assisted Lipectomy
      20. Cryotherapy for Acne
      21. Electrolysis Epilation
      22. Mastopexy
      23. Reduction Mammoplasty
      24. Augmentation Mammoplasty
      25. Breast Reconstruction
      26. Application of Halo Type Appliance for Maxillofacial Fixation
    2. Experimental and other Excluded Services. Examples of Experimental and other Excluded Services include but are not limited to:
      1. Acupuncture
      2. Intestinal bypass surgery
      3. Intravenous histamine therapy monitoring
      4. Joint and ligament sclerosing therapy
      5. Chelation therapy for atherosclerosis
      6. Cochlear implants (under 18 years of age)
      7. Cytotoxic food tests
      8. Electrosleep therapy
      9. Food allergy testing
      10. Gastric balloon for treatment of obesity
      11. Hair transplants
      12. Heat treatment for pulmonary conditions
      13. Hemodialysis for Schizophrenia therapy
      14. Mammoplasty, cosmetic
      15. Sex-change operations
      16. Tattoo removal
      17. Tinnitus masking
      18. Plastic surgery (purely cosmetic, not reconstructive)
      19. Portable hand held x-ray instruments
      20. Pulmonary embolectomy, transvenous (catheter)
      21. Electric aversion therapy
      22. Electric nerve stimulation for motor dysfunction (not pain control)
      23. In-vitro fertilization
      24. Ambulatory blood pressure
      25. Artificial Hearts
      26. Cellular therapy
      27. Keratoplasty, refractive
      28. Colonic irrigation
      29. Dermabrasion
      30. External counterpulsation
      31. Gastric freezing
      32. Hair analysis
      33. Human tumor stem cell drug
      34. Rhinoplasty, cosmetic
      35. Sensitivity assays
      36. Scalp replantation
      37. Thermogenic therapy