Patient Handbook

The mission of the Pleasant Point Health Center is to provide the highest quality of health care available to the community we serve. 

We are funded through a contract with the Federal Indian Health Services. The Pleasant Point Health Center operates as a local comprehensive Health Care Delivery System under the “P.L. 638, Indian Self Determination Act.” Our primary contracting office is located in Nashville, Tennessee. Alternate Resources, such as payment from Medicaid, Medicare, Veterans’ Benefits, and Private insurance, provide additional funding to provide essential services to our community. We rely heavily on income from third party payers, as the level of funding that we receive from Indian Health Services is limited.

If you have any questions, or would like to discuss any aspect of health care delivery, please feel free to call us at (207) 853-0644.

Regular hours of operation: Monday – Friday from 8:00 AM – 4:30 PM

Routine and Follow-up appointments are scheduled for patients by the receptionist (Please provide 24-hour notice for cancellations.)

Pharmacy: Monday – Friday from 8:00 AM – 4:30 PM. 

Dental: Monday – Friday from 8:00 AM – 4:30 PM

Patient Registration:

All new patients must report to the Patient Registration Office to be signed up for services.

The process of registering at the Pleasant Point Health Center takes just a few minutes. Please come early for your appointment so that we may have the opportunity to complete your file. Stop by the front desk to report any changes to your file. We require the Patient Registration Form to be updated each visit.

Note: We have MaineCare applications forms at the clinic, and our Patient Registration staff are able to assist you with filling out and sending these forms. 

Purchased and Referred Care:

Purchased and Referred Care Services are those services that are provided by outside agencies for eligible members of the Passamaquoddy Tribe at Pleasant Point. The referral for these types of services arises when the patient’s provider sees the need for more specialized services in order to maintain the health of the patient. Funds may be available for these services, and are provided as part of our contract from Indian Health Services.

In order to receive a referral for services outside of the clinic, a patient must:

  1. Visit their provider at the Pleasant Point Health Center to determine if a referral for outside services is necessary.
  2. The patient’s eligibility will be determined by the Purchase and Referred Care’s eligibility requirements.
  3. A managed-care team determines if the referral is eligible for payment, which is based on a priority system. 
  4. Patients are required to apply for alternate resources. 

 

ALL PATIENTS MUST BE REFERRED BY THE HEALTH CENTER AND REVIEWED IN MANAGED CARE TO ENSURE PAYMENT. THIS INCLUDES FOLLOW-UP APPOINTMENTS.

Third Party Billing:

The Pleasant Point Health Center, through payment for services from third party payers, has established a budget that is commonly known as the “ Third Party Budget.” The Authorization to create this funding is authorized by the Indian Health Services through their Nashville Area Office.

The Third Party money pays for wages of some employees at the Pleasant Point Health Center, but a majority of the funds collected go back into direct services to our community. Many of the services offered are paid for by Third Party. They include, but are not limited to:

  1. On-site Specialty Clinics: Optometry and Podiatry
  2. Eyeglasses and Hearing Aids
  3. Transportation assistance for the Elders and Disabled
  4. Purchased and Referred Care (Outside Referrals)
  5. Other types of specialty assistance when funds are available

 

These services are just some of the reasons why it is so important for us to have your health insurance information. When we bill for services provided at the clinic, all of the money collected comes back to our community in the form of additional programs and services.

Medical Records:

The Medical Records Department houses the files of all medical patients at the Pleasant Point Health Center. We are open Monday through Friday from 8:00 AM – 4:30 PM.

We adhere to the Policies and Procedures set forth by Indian Health Services and work diligently to protect the CONFIDENTIALITY of all patients. If a patient requires information, please note the following:

  1. Obtain a signed release for medical records to and from the Pleasant Point Health Center
  2. Provide 24-hour notice for photocopying of chart information

 

The Medical Records Department is unable to accept “ verbal” results from outside providers. Also, we cannot give patients results over the telephone.

Emergency-Room Visits Require 72-Hour Notification:

All patients (or someone operating on their behalf) are required to notify the Pleasant Point Health Center within 72-hours of emergency room visit, unless a Medical Provider of the Pleasant Point Health Center has issued a referral. 

Payment will be based on priorities, and failure to provide proper notice within 72-hours will result in non-payment of any bills associated with the Emergency Room Visit (42 CFR 36.2).

If you have been denied payment for services, you may appeal the decision by submitting, in writing, a letter explaining why you feel it should be paid and any supporting documentation. Any appeal must be done within 30-days of the receipt of a denial letter. All requests for appeal are reviewed by the Quality Assurance Managed Care Team to ensure that a correct decision has been made.

Health Services for Ineligible Persons:

For individuals who are not eligible for our health services, medical care may be administered in the following cases:

  1. To achieve stability in a medical emergency
  2. To prevent the spread of a communicable disease or otherwise deal with a public health hazard
  3. To provide care to non-Indian women pregnant with an eligible Indian child for the duration of the pregnancy through postpartum.

I. Emergency/Acutely Urgent Care Services DEFINITION:

Diagnostic or therapeutic services which 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 Covered Services: (random order)

  1. Emergency room care for emergent/urgent medical conditions, surgical conditions or acute trauma
  2. Emergency impatient care for emergent/urgent medical conditions, surgical conditions or acute injury
  3. Renal dialysis, acute and chronic
  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 illnesses or conditions
  6. Obstetrical deliveries and acute prenatal care
  7. Neonatal care


II. Preventative Care Services:

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). Level II services are available at most I.H.S facilities.

Categories of Services included (random order)

  1. Routine prenatal care
  2. Non-urgent preventive ambulatory care (primary prevention)
  3. Screening for known disease entities (secondary prevention
  4. Screening Mammograms
  5. Public Health Intervention


III. Primary and Secondary Care Services:

Inpatient and outpatient care services that 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 includes services that may not be available at many I.H.S 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, dermatology
  3. Elective, routine surgeries that have a significant impact on morbidity and mortality
  4. Diagnostic evaluations for non-acute conditions
  5. Specialized medications no available at I.H.S facility when no suitable alternative exists


IV. Chronic Tertiary and Extended Care Services:

Inpatient and outpatient care 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 I.H.S facilities. Careful case management by the Managed Care Committee is a requirement.

Categories of Services Included (random order)

  1. Rehabilitation care
  2. Skilled nursing home care
  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 (HCFA approved organs only)
  8. Care provided under the direction of an advance directive


V. Excluded Services:

Services and procedures that are considered purely cosmetic in nature, experimental or investigation, or have no proven medical benefit.

  1. Cosmetic Procedures – Payment for certain cosmetic procedures may be authorized if these services are necessary for proper mechanical function or psychological reasons. 
  2. Experimental and other Excluded Services – Payment is not authorized, unless the Office of Health Programs, at the Indian Health Services/Nashville Area Office, has granted a formal exception.

 

Categories of Excluded Services:

  1. All purely cosmetic (not re-constructive) plastic surgery
  2. Procedures listed as experimental by HCFA
  3. Procedures for which there is no proven medical benefit – procedures listed as “ Not Covered” in the Medicare Coverage Issuance Manual, Section 27,200
  4. Extended care nursing homes (intermediate or custodial care)
  5. Alternate medical care (homeopathy, acupuncture, chemical endarterectomy, naturopathy)