Who is Eligible?
To be eligible for Contract health care through CVIH, the patient has to be a documented California Indian who is a resident of the CVIH health services delivery area (Fresno, Madera or Kings counties excluding Table Mountain Rancheria tribal members or any tribe that has pulled out of CVIH). Local tribal and Dunlap area students, who are attending college out of the area, may continue to receive contract care.
Documented Indian means acceptable documentation such as a member of a federally recognized tribe; documentation from the Bureau of Indian Affairs; inclusion on the California Rolls. Descendants have to provide documentation in the form of birth certificates from someone on the rolls. There are a few other means of documentation that are considered on a case by case basis.
Most Purchased/Referred Care is given through pharmacy prescriptions. Purchased/Referred Care patients do not need purchase orders for prescriptions, but must get a purchase order prior to receiving services for any referral given by a medical or dental provider. CVIH Providers electronically issue referrals to the CVIH Referral Clerks, who will get insurance approval and issue purchase orders as needed.
how does purchased/referred care work if you already have insurance?
Purchased/Referred Care is payer of last resort. What that means is if you have insurance your insurance will be billed for the services and Purchased/Referred Care will pick up your co-payment and anything that the insurance does not cover-as long as it is a covered. Purchased/Referred Care service pharmacy prescription from contract pharmacies, special medical and dental referral by a CVIH provider, and dental laboratory). CVIH never gets money from Purchased/Referred Care if your insurance has already been billed for the service. Purchased/Referred Care will only pay what your insurance does not pay with regard to patient responsibility.
How to receive services
To learn more about your eligibility to receive services, either download the forms and bring them completed into the clinic or stop by the clinic to get the forms, complete them and speak to one of our PRC/Eligibility Clerks for assistance. You can fill out the form electronically and upload it here.
559-299-2578 Ext 1812
Benefits and Requirements
Native American patients, seen at an Indian Health clinic, such as Central Valley Indian Health (CVIH), are eligible for certain benefits under Direct Care or Purchased/Referred Care services. The following is an explanation of benefits and the eligibility requirements in these areas.
direct care services
The benefits under Direct Care services include visits to any Central Valley Indian Health clinic, including medical, dental, nutrition, mental health counseling and social services at no charge. You will be asked to pay for any laboratory (medical and dental), x-ray, prescriptions and visits to physicians outside CVIH, including optometry.
Eligibility for Direct Care benefits requires that you be able to provide documentation of your Native American heritage. Federally recognized out of state tribal members and their descendants, Native Americans living outside of the CVIH service area including Table Mountain Rancheria tribal members or any tribe that has pulled out of CVIH will be considered eligible for Direct Care services.
For more information or questions, please see the Eligibility at the Clovis clinic or call 559-299-2578 Extension 1812
Purchased/Referred Care Services consists of certain benefits that are in addition to the clinic visits for direct care*, and are available as funding allows, including:
1. Laboratory studies
2. X-ray and imaging studies, including MRI’s & CT scans
3. Pharmacy prescriptions, but only from CVIH Contract pharmacies*
4. Specialty referrals
5. 100% of the costs for dental laboratory work, crowns and dentures
6. Limited dental specialty referrals; braces and or retainers as funding allows.
7. Optometry services include the exam, glasses up to one pair annually (frames and lenses) or contact lenses.
A. All repairs, including broken glass- es, will be handled at no cost to the patient. If under warranty, CVIH will cover any costs above what is covered by the warranty.
B. School kids who break their glasses and need a replacement will be eligible for one extra pair per year.
C. CVIH patients will be able to choose frames and lenses from the CVIH Staff Optician.
D. Patients choosing to go somewhere other than CVIH for their glasses do not need a purchase order and can submit a receipt to CVIH for reimbursement up to the $100 limit.
8. Hearing aids for children and adults are available through PRC. The number of hearing aids that a patient may receive under the CVIH policy will be determined by the referring physician. Batteries and repairs are covered annually, as needed. Dependent on funding and CVIH provider recommendation based on medical necessity.
9. Minor surgeries, outpatient only may be covered.
10. Electronic Medical History bracelet or card with doctor recommendation only
*Purchased/Referred Care referral services are available for most medical and dental referrals based on funding availability.
**Pharmacy prescriptions will be subject to the CVIH formulary, which is a listing of medicine for which CVIH will authorize payment. Over the counter medicines (OTC) are limited to those distributed at the clinic. Most Indian Health Programs do not authorize payment for OTC’s.
Purchased/Referred Care is provided by CVIH when the patient is under the care of a CVIH provider. The exception is for patients under the care of a specialist (must have been referred by CVIH) or those who are referred by the after hours doctor. Beyond that, there are no exceptions. CVIH can’t provide Purchased/Referred Care services to patients who see other doctors for two reasons. First, the Indian Health Service Regulations on Purchased/Referred Care says that we can’t, and the Indian Health Service is the funding authority. Second, liability is assumed by CVIH for paying for the services. If the doctor is not working at or for CVIH, we do not have any control over his or her credentialing or privileging.
The reason for the limitations is due to a study by the Indian Health Services that is called the Level of Need Funded (LNF), which determined that CVIH is one of the four lowest funded programs in the nation. Though work is being done to improve that standing, it will take many years to catch up with the other programs. Additionally, there is a law in effect that will not allow the Indian Health Service to take from higher funded programs to give that to CVIH to attain some equality. All increases have to come from new funding for the Indian Health Service.
Due to these funding restrictions, Purchased/Referred Care cannot pay for Emergency room visits, hospitalizations/inpatient care or surgery.
Contact the Purchased/Referred Care Dept.
You may also securely upload any relevant documents to our PRC Department below.