42 C.f.r. 136.24

Public Health Service, HHS

§ 136.25

population residing in a contract
health service delivery area, priorities
for service shall be determined on the
basis of relative medical need.
(f) Alternate resources. The term ‘‘alternate resources’’ is defined in
§ 136.61(c) of Subpart G of this part.

riod may be extended if the ordering official determines that notification
within the prescribed period was impracticable or that other good cause
exists for the failure to comply.

[64 FR 58319, Oct. 28, 1999. Redesignated and
amended at 67 FR 35342, May 17, 2002]

(a) 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.
(b) 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.
(c) 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.

§ 136.24 Authorization for contract
health services.
(a) No payment will be made for medical care and services obtained from
non-Service providers or in non-Service
facilities unless the applicable requirements of paragraphs (b) and (c) of this
section have been met and a purchase
order for the care and services has been
issued by the appropriate ordering official to the medical care provider.
(b) In nonemergency cases, a sick or
disabled Indian, an individual or agency acting on behalf of the Indian, or
the medical care provider shall, prior
to the provision of medical care and
services notify the appropriate ordering official of the need for services and
supply information that the ordering
official deems necessary to determine
the relative medical need for the services and the individual’s eligibility.
The requirement for notice prior to
providing medical care and services
under this paragraph may be waived by
the ordering official if:
(1) Such notice and information are
provided within 72 hours after the beginning of treatment or admission to a
health care facility; and
(2) The ordering official determines
that giving of notice prior to obtaining
the medical care and services was impracticable or that other good cause
exists for the failure to provide prior
notice.
(c) In emergency cases, a sick or disabled Indian, or an individual or agency acting on behalf of the Indian, or
the medical care provider shall within
72 hours after the beginning of treatment for the condition or after admission to a health care facility notify the
appropriate ordering official of the fact
of the admission or treatment, together with information necessary to
determine the relative medical need for
the services and the eligibility of the
Indian for the services. The 72-hour pe-

§ 136.25

Reconsideration and appeals.

Subpart D [Reserved]
Subpart E—Preference in
Employment
AUTHORITY: 25 U.S.C. 44, 45, 46 and 472; Pub.
L. 83–568, 68 Stat 674, 42 U.S.C. 2003.

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