Form no. 02712 CNDC-TCH Rev.8/2019
PROGRAM GUIDELINES
The Chickasaw Nation Department of Commerce (CNDC) will extend this benefit to its enrolled Chickasaw citizens to help
them in accessing unmet medical care, dental care, and durable medical equipment. The CNDC will certify eligibility
through its program participation guidelines as follow.
Total program assistance may not exceed $5,000 per fiscal year (October 1 through September 30 of the following
year). Any fees over this maximum benefit are the financial responsibility of the applicant or guardian. Payment
arrangements for any remaining balance will need to be made directly with the providers of care before obtaining
services.
Applicants must first exhaust all alternate resources such as private insurance, sports insurance offered through school
systems, Medicare/Medicaid, Veteran’s Administration, Indian Health Service or Chickasaw Nation programs.
o Citizen must utilize IHS facility within 150 miles of primary residence for available services.
o This includes providing documentation of the denied/deferred claim from the Indian Health Service unit.
o Patients residing within the Chickasaw Nation services unit must have a referral written by Chickasaw Nation Department
of Health (CNDH) provider for services not available within CNDH.
o Patient required to receive treatment within their insurance network.
o Patient required to follow insurance requirements for the service
Prior authorization of services and DME requested except in emergent situations.
Documentation of medical necessity for the service will be required with the application.
Children Orthodontics (18 and under) on lifetime benefit of $5000.
The Chickasaw Nation Tribal Health multidisciplinary committee will review medical or dental claims.
If an application is denied, written notification will be sent to the applicant/parent/guardian. A written appeal of the denial may
be sent to the attention of the director of tribal health.
Claims should be submitted within 180 days of services rendered.
Tribal health reserves the right to negotiate reduction in billed medical claims at or below Medicare allowable.
Tribal health services are available to assist help with unmet medical dental and durable medical equipment needs of citizens
when all other resources have been exhausted.
Document(s) when requested by Tribal Health must be returned within 45 days of request.
Appointment or procedures must be schedule within 60 days of approval letter.
All services received are ultimately the patient’s responsibility as the agreement is between the patient and provides.
Acknowledgement of the guidelines of the tribal health program
PROGRAM EXCLUSIONS
1. Any medical or dental services available or reasonably accessible in an Indian Health Service or Chickasaw Nation medical facility.
2. Injury resulting from negligent or unlawful acts such as traffic violation or negligent acts as a driver or passenger, criminal
activity, or participation in acts of aggression, such as fighting, boxing and rioting.
3. Injury resulting from an accident covered by worker compensation, automobile or home/business liability insurance.
4. Care requested while incarcerated or in law enforcement custody.
5. An illness or injury occurring while intoxicated or under the influence of illegal substances or from use of any narcotic,
barbiturate or any other drug, unless taken or used as prescribed by a physician (does not exclude addiction recovery).
6. Services or durable medical equipment deemed not medically necessary or considered elective: examples include genetic testing for non-
covered medical conditions, non-standard durable medical equipment, cosmetic procedures (except restorative surgery after cancer
treatment), Lasik corrective eye surgery, fertility treatment, Botox, performance enhancement, or experimental procedures.
7. Services not within the scope of program: examples include long-term care, Hepatitis C treatment or related services, marijuana or
homeopathic pain management, hormone supplements not approved by FDA, reimbursement request for prescriptions and second opinions.
Signing below is acknowledgement the applicant/guardian accepts and understands the guidelines and exclusions of the
Chickasaw Nation Tribal Health Program.
Signature of applicant/guardian Date
