EASTERN SHAWNEE TRIBE OF OKLAHOMA
HEALTH & SOCIAL SERVICE PROGRAM
GENERAL INFORMATION—The Eastern Shawnee Tribe of Oklahoma’s Health & Social Service Program is funded by tribal business ventures. The program offers assistance for school expenses, healthcare, burial, utilities and elder/disabled care needs for all tribal members. The program operates on a tribal budget that has a maximum for payment on each service that has been set by the Business Committee. The program follows a 1st come 1st serve basis. The program operates on the fiscal year (October 1—September 30.) The guidelines and requirements for this program are as follows:
- All claims must be submitted within 90 days from the date of service or insurance payment and must be submitted or postmarked on September 30th to be processed for that fiscal year. Any claims submitted after 90 days will be returned to you and will be your responsibility. All claims shall be subject to the availability of funds.
- Only enrolled members of the Eastern Shawnee Tribe of Oklahoma are eligible to apply and receive services from this program. Future tribal members will be eligible for services after date of enrollment and all dates of service must be on or after enrollment date. Services are for every member regardless of income, age or residence, unless stated otherwise. Payments will be made to the parent who has been adjudicated custody of the child/children by a court of law.
- All tribal members must have an Authorization to Release Information form on file. In order to release certain information to family members, an Authority to Release Information to a Designated Individual form must be on file.
- Payments will be made to vendors when at all possible. This does not include utilities, unless stated otherwise. However, applicants paying for services at time of service can be reimbursed upon receipt of a paid invoice. If you have healthcare insurance complete the Coordination of Benefits Questionnaire and file all claims with your insurance company first. We will reimburse only your out-of-pocket expenses.
- For reimbursement of expenses, complete a Reimbursement Request form and attach ORIGINAL documentation along with proof of payment. Documentation must show the business name with date of service or purchase. DO NOT highlight or write on any receipts as they could be considered altered and will not be processed. For direct payment to vendors, complete a Direct to Vendor Payment Health Expense Claim form and attach ORIGINAL billing statement. Make copies of all your paperwork for your records as originals will not be returned. There is a $25 minimum check amount.
- Please allow a minimum of 30 days for your claim to be processed for a reimbursement check to be issued. The Health & Social Service Department and the Accounting Office both encounter tremendous work load requirements. Calling staff inquiring as to the status of a claim only creates a setback for the Departments in completing your claims in the time allotted.
- There is a $30 fee for each stop payment request that is processed. If a stop payment of check is required, the tribal member agrees to hold the Eastern Shawnee Tribe harmless for the stop payment fee. The Eastern Shawnee Tribe will not be responsible for any fees due to inadvertence on the tribal members part.
- Any person willfully attempting to defraud the Eastern Shawnee Tribe will not be considered for any services of this program. The Business Committee reserves the right to revoke, suspend, or terminate the eligibility of any tribal member for a period of time to be determined and set forth by the Committee.
PRE-AUTHORIZATION OF TREATMENT
It is highly recommended that a provider obtain prior authorization for treatment in order for the claim to pay according to your benefits. A pre-authorization is a request made prior to a procedure to verify benefits. This allows the patient to make an informed decision of potential coverage for the procedure in advance. The pre-authorization assists not only the provider to expedite their workflow but is a benefit for you as well. You will have advance notice of the extent of the work involved—health wise and financially.
SUBMITTING YOUR CLAIM
For reimbursement or direct payment of expenses, complete either the Reimbursement Request or the Direct to Vendor Payment form along with your ORIGINAL paperwork. Do not highlight or write on the receipts, as they could be considered altered and will not be processed. Receipts must show the business name with date of purchase. Direct payment to a vendor must show the name of the tribal member, address and telephone number of the facility, type of service received, date of service and all charges. The entire original bill for payment to vendor is required. Submitting just the bottom or top portion of a bill will not be accepted.
You must file your claims with any Primary provider first. The program will only pay or reimburse for out-of-pocket expenses incurred from the unmet expenses not paid by the primary provider. Funds can be used only after all other resources have been exhausted. Failure to comply with alternate resource policies may result in the denial of future services. Any duplicate payments made by the Health & Social Service Program and a Primary Provider must be returned to the Eastern Shawnee Tribe of Oklahoma. Failure to reimburse the tribe may result in denial of future services.
Some benefits require more than just a receipt or a direct to vendor payment. The following are additional documentation that must be enclosed with your request:
- School supply expenses must be accompanied by the school supply list provided at the beginning of each school year. Other school supplies required throughout the school year must be accompanied by a statement from the teacher that child needs that particular item for their school curriculum.
- Healthcare expenses must be accompanied by your insurance Explanation of Benefits (EOB) and proof of payment to healthcare facility.
- You must supply an explanation from the doctor as to the medical necessity for special medical equipment/supplies or orthodontics. Keep in mind that over-the-counter and homeopathic medicines do not apply.
- The customer/duplicate prescription receipt or pharmacy printout must be provided. No cash register receipts.
- Burial expenses must be accompanied by a copy of the death certificate and/or the original state certified birth certificate that proves the paternal/maternal relationship for a non-enrolled child.
FRAUDULENT SANCTIONS POLICY
The Eastern Shawnee Tribe of Oklahoma is a federally recognized Indian tribe; therefore theft of funds from the tribe is a criminal offense, which is punishable by law. This policy was created in order to protect the trust tribal members have placed in the staff of the Eastern Shawnee tribal office and conduct the Health & Social Service programs with integrity. This will insure that funds continue to be available to all the tribal members who have needs and qualify for Health & Social Service benefits. The following actions will occur with any fraudulent claims submitted…
- ATTEMPTED FRAUD – Warning with denial of claim package that contained fraudulent material. Multiple attempts shall result in the review of suspension of services.
- PROVEN FRAUD – One (1) year household suspension from ALL tribal programs, with suspension permanent until repayment of all monies are reimbursed to the tribe.
- REPEATED FRAUD – Suspension to be determined by the Social Service Review Board. Suspension could range as far as lifetime banishment from ALL tribal programs.
TITLE 18>PART 1>CHAPTER 53>§ 1163
EMBEZZLEMENT AND THEFT FROM INDIAN TRIBAL ORGANIZATIONS
Whoever embezzles, steals, knowingly converts to his use or the use of another, willfully misapplies, or willfully permits to be misapplied, any of the moneys, funds, credits, goods, assets, or other property belonging to any Indian organization or entrusted to the custody or care of any officer, employee, or agent of an Indian tribal organization; or Whoever, knowing any such moneys, funds, credits, goods, assets, or other property to have been so embezzled, stolen, converted, misapplied or permitted to be misapplied, receives, conceals, or retains the same with intent to convert it to his use or the use of another—Shall be fined under this title, or imprisoned not more than five years, or both; if the value of such property does not exceed the sum of $1,000, he shall be fined under this title, or imprisoned not more than one year, or both. As used in this section, the term “Indian tribal organization” means any tribe, band, or community of Indians which is subject to the laws of the United States relating to Indian affairs or any corporation, association, or group which is organized under any of such laws.
If your claim is denied, you may appeal the decision in accordance with the following procedure…
Step 1 – - A written appeal to the Program Director for reconsideration. You will have ten (10) working days from the date of the written denial to appeal the decision.
Step 2 – - If the matter is not resolved to your satisfaction in Step One of the appeal, you may submit a written appeal to the Social Service Review Board. The Board will review your request and notify you of their decision within ten (10) working days from the date of your appeal.
Step 3 – - If the applicant is not satisfied with the decision of the Review Board, a written request stating the condition of the appeal may be submitted to the Eastern Shawnee Business Committee for consideration at a regular scheduled Business Committee meeting. The applicant may be requested to appear at the meeting.