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Purchased & Referred Care

PRC News

 

PRC Eligbility Cards

PRC eligibility cards are issued to eligible patients as proof of alternate coverage to the patient's primary insurance provider.

Patients must carry their PRC card with them for any services outside of CTHP that may be covered by PRC.

If patients lose their card, call PRC to request a replacement.

 

Billing and Payment

If patients receive a bill from a provider, they can bring it to the PRC office as soon as possible for review and approval.

The patient will be informed as to whether or not all or part of the bill can be covered by PRC.

If patients receive a payment from a provider for a bill that PRC already paid, the patient must reimburse PRC the amount.

 

 

About Purchased and Referred Care

CTHP’s Purchased & Referred Care Program supplements direct care services at CTHP for our active AI/AN patients.  

Congress funds CTHP’s PRC program annually for the purpose of assisting eligible AI/AN (American Indian/Alaska Native) patients with medical, dental and some hospital services not provided by CTHP.

CTHP’s Board of Directors approves the policy and determines the levels of care to be covered.

PRC is not an entitlement program. Eligible expenses are covered as funds are available.

PRC is considered a payor of last resort. Patients are required to apply for and use alternate resources such as Medi-Cal, private insurance, Healthy Families, Medicare, etc.

Eligibility

Proof of Eligibility is in three parts: Indian eligibility, residency and alternate resources.

Indian eligibility is determined by one of the following:

  1. Any member of a federally-recognized Indian Tribe, or

  2. Any descendant of an Indian who was residing in California on June 1, 1852, but only if such descendant; is a member of the Indian community served by a local program of the Service, and is regarded as an Indian by the community in which such descendant lives.

  3. Any Indian who holds trust interests in public domain, national forest, or Indian reservation allotments in California.

  4. Any Indian in California who is listed on the plan for distribution of the assets of California Rancherias and Reservations under the Act of August 18, 1958 (72 Stat. 619), and any descendant of such an Indian.

Required Documentation

Tribal or Bureau of Indian Affairs certification of Indian status

A descendant must provide a certified birth certificate to show lineage to the eligible Indian.

Proof of Residency must be provided for the following:

Tribal members located and/or residing on a Rancheria/Reservation whose Tribe does not have its own Tribal PRC Program.

Out-of-State Indians (individuals who are members of out-of-state Tribes) are eligible for PRC only if they reside in CTHP’s Purchased/Referred Delivery Area and provide Tribal verification that patient maintains close socio-economic ties to that Tribe; or

California Indians and their descendants must reside in CTHP’s PRC Delivery Area: Mendocino County, excluding Round Valley and Manchester/Point Arena.

Rental agreement, utility bill with patient name, or written verification from the head of household with whom patient resides.

American Indian/Alaska Native patients who apply for alternate resources but are denied coverage will receive a denial letter. The denial letter must be provided when requesting PRC support

Private Insurance:  When an eligible CTHP patient of CTHP’s PRC Program is enrolled in a private insurance plan, the CTHP PRC Program will pay the deductible and /or balance of the bill when the services have been referred by CTHP.

If patients belong to an HMO or Managed Care System, (i.e. Kaiser Foundation, Marshall MedPlan, etc) the patient will be referred to theirprimary care physician for the necessary services, and coverage under their medical program.

When a Patient Receives a Payment from (an) Alternate Resource(s)

If a patient receives payment(s) from their alternate resource(s) for something that PRC paid for, it is the patient’s responsibility to reimburse PRC the amount received.

PRC requires the following documentation: an explanation of benefits from the insurance company and a current bill for services before balance of the co-pay or deductible is paid.

Level of Care

The level of care is developed using IHS guidelines and is approved by CTHP’s Board of Directors.

Prior Payment Authorization

Prior payment authorization is required for all non-emergency services and follow-up visits.

Only eligible AI/AN patients referred by CTHP providers to outside providers may receive assistance from PRC, depending upon funding availability.

Each medical/dental follow-up visit and procedure or surgery must receive prior approval.

Every referral needs prior authorization from CTHP PRC Program before service is rendered.

Secondary referrals made from other providers need to have prior authorization from PRC before service is rendered.

It is the patient’s responsibility to schedule and attend all referral appointments, and to arrange their transportation.

Denials and Appeals

In the event of a denial from PRC, a letter will be sent to the patient stating the reason for the denial and the procedure for filing an appeal.

If the patient decides to appeal, the patient may send their appeal letter and supporting documentation to:

Executive Director

Consolidated Tribal Health Project, Inc.

P. O. Box 387

Calpella, CA   95418

Attention: PRC Appeal

PRC Contacts
Karen Shepherd, PRC Supervisor:  707-467-5617

Antoinette Ascencio, Patient Resource Advocate: 707-467-5641

Kayla Kryla, Patient Resource Advocate: 707-467-5604

Kayla Lowell, PRC Clerk:  707-467-5608

FAX: 707-485-5291

Links and Resources

Indian Health Service

https://www.ihs.gov/prc/

 

PRC Fact Sheet

 

Covered California

http://www.coveredca.com/

Insure Kids Now

http://www.insurekidsnow.gov/

HealthCare.gov

www.healthcare.gov

Subsidy Calculator

http://kff.org/interactive/subsidy-calculator/

Health Insurance Explained

http://kff.org/health-reform/video/health-insurance-explained-youtoons/?utm_source=kff&utm_medium=tile&utm_content=home&utm_campaign=consumer

Health Coverage for American Indians/Alaska Natives

www.healthcare.gov

Tribal Health Care

http://tribalhealthcare.org

 

 

 

 

page updated 06/23/17

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