About Purchased & Referred Care
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.
Proof of Eligibility is in three parts: Indian eligibility, residency and alternate resources. Indian eligibility is determined by one of the following:
Any member/citizen of a federally-recognized Indian Tribe
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
Any Indian who holds trust interests in public domain, national forest, or Indian reservation allotments in California
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
Be sure to bring your Tribal or Bureau of Indian Affairs certification of Indian status to your registration meeting. 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/citizen 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
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 their primary 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:
Attention: PRC Appeal
Consolidated Tribal Health Project, Inc.
P. O. Box 387
Calpella, CA 95418
Karen Shepherd, PRC Supervisor: (707) 467-5617
EarlyJim James Patient Resource Advocate: (707) 467-5604
Kayla Lowell, PRC Clerk: (707) 467-5608