Through PRC, the Siletz Tribe can buy services that are unavailable at the Siletz Clinic or other IHS facilities. Please read the Purchased/Referred Care (PRC) Users Guide for a list of situations where PRC would be used, eligibility requirements and more.
The Purchased/Referred Care Phone Number is Changing!
Starting May 1st, you can call PRC directly at 541-444-9677.
This update allows you to contact PRC directly- no more transferred calls or phone trees!
All other PRC phone numbers will be deactivated within the coming months. Until then, an automated voice message will direct callers to contact PRC using our new number.
Hours
Monday, Tuesday, Thursday & Friday
8:00 AM – 4:30 PM
Wednesday
12:00 PM – 4:30 PM
Contact
Pre-authorization and notification within 72 hours is required.
Phone: 541-444-9677
Fax: 541-444-9645
Email Option
You can now receive your Patient and Referred Care (PRC) Pre-Authorizations and send your billing inquiries to SiletzPRC@ctsi.nsn.us.
Pre-authorization and notification within 72 hours is still required.
In your email include the following information:
- Subject (ex: Authorization number or Billing Inquiry)
- Name of Clinic
- Name of Provider
- Date of appointment
Emergency Room Gatekeeper
During regular business hours, call the Siletz Clinic. After regular business hours, on weekends, or holidays please call 800-628-5720 or 541-444-1236. You will be directed to the answering service, the physician on call will be alerted.
Staff
Selina Rilatos
Healthcare Reimbursement Technician II
Christine Knott
Healthcare Reimbursement Technician II
Joella Strong
Healthcare Reimbursement Technician I
Monica Wolf
Healthcare Reimbursement Assistant
Heather Warren
Healthcare Reimbursement Assistant
Questions Commonly Asked
Why didn’t PRC pay a bill I mailed to them (or dropped off at clinic)?
The facility MUST send a bill PRC directly. The facility will send the bill on an appropriate claim form (a UB-04, CMS-1500 or ADA) that provides necessary details to process a claim. If you get a bill, please contact the facility and ask them to bill PRC as your secondary (or primary) insurance. Although PRC is a benefit and not an insurance, the billing process is the same.
Why does it take so long for PRC to pay my bill? My doctor’s office said they’ve sent 3 claims.
There should only be a delay if we’ve never paid the provider before. PRC requires the facility to provide a W-9 tax form before a payment can be made. After receiving a W-9 from a facility, PRC then performs a TIN (Taxpayer Identification Number) match with the IRS. If a TIN match cannot be made then the W-9 is rejected and a new form is then requested.
What do I do if I get a bill that PRC should pay – I have an authorization #?
Notify the facility that they need to bill PRC – ASAP.
What types of visits needs to go through the Gatekeeping Review Committee?
All visits for Specialty Care and Imaging.
Why did my visit get denied by PRC?
This can happen for several reasons. The most common reason is that it was not called in to PRC.
How can I prevent bills from being denied?
Call your visit in as soon as you know that you have an appointment. This will ensure PRC has time to verify that your annual update is completed, you have applied for or shown that you are over income for Oregon Health Plan, and to confirm if the visit needs to go through the Gatekeeping review process.
How to Avoid Denials with PRC
- Make sure you have completed an annual update. If you are not sure you are due for an update, then you probably are.
- If the patient benefit coordinator reaches out for Oregon Health Plan information, please respond. If you do not have other insurance, you will not be required to pay for it, but if you qualify for OHP, then you must apply for it. If you do not participate with the patient benefits coordinator, you will not be eligible for services until that has been done.
- Call in all visits in to PRC immediately after the appointment is created or changed.
- Specialty care must go through the Gatekeeping Review Committee. Once you have received your approval letter in the mail, schedule your appointment then call Purchased Referred Care for your authorization number. Specialty care is anything that cannot be done at your Primary Care Providers office.
A Reminder to PRC Eligible Tribal Members
All tribal members that live within a 40 mile radius must receive Medical, Dental and Vision care and services at one of the 3 Indian Health Service (I.H.S.) or tribal health care facilities.
If you are unsure whether you live within the 40 mile radius, please contact Siletz PRC using the contact information listed above.
Contact numbers for the Indian Health Service (I.H.S.) or tribal health care facilities:
Siletz Community Health Clinic: 1- 800-648-0449
Chemawa Health Clinic: 1-800-452-7823
Grand Ronde Health & Wellness Center: 1-800-422-0232
Ko-Kwel Wellness Center: 541-916-7025
NARA NW Wellness Center: 971-279-4800
NARA NW Dental Clinic: 971-347-3009
NARA NW Indian Health Clinic: 503-230-9875
Utilization of these facilities is required, unless being referred out for Specialty Care.
Alternate Healthcare Benefits
Alternate Healthcare benefits are available to all enrolled Siletz Tribal members. Dependents and descendants are not eligible for alternate healthcare benefits. We do request that you have completed an individual registration application and have updated with the Siletz Community Health Clinic before obtaining authorization for Alternate healthcare benefits. Updates can be emailed to medicalrecords@ctsi.nsn.us.
The benefits that are available are acupuncture, chiropractic care, and naturopath and massage therapy. These benefits are available 4 times per year at the beginning of each quarter as long as funding is available. It is on a 1st come 1st serve basis. A tribal member just needs to contact PRC and request which benefit they would like.
The patient will then receive a letter that lets them know what they are eligible for, how many visits, and the benefit $ amount. The letter also provides information that they can give to their provider, so they are aware of the payment process. Each patient is eligible for a maximum of 3 visits up to $75.00 per visit per day per quarter. Anything over that becomes patient responsibility.
Newly Available Services – PRC Funding for Specialty Surgery
Tribal Council approved funding for medically necessary surgeries that are not currently approved services. To qualify you must be an enrolled Siletz tribal member AND PRC eligible.
Eligible Surgeries:
- Excess eyelid skin removal
- Breast reduction
- Excess abdominal skin removal
PRC will process requests through Gatekeepers; funding is limited and will be first come/first serve. The established medically necessary criteria is consistent with CMS and insurance guidelines. Requests deemed as cosmetic will not qualify.
2023 Out of Area Health Benefits
Tribal Council has allocated excess pledge revenue/3rd party revenue for health benefits. These benefits are for Tribal Members who live outside the 11 county service area. Tribal Members must be registered for health care with the Siletz Tribal Health Department AND reside outside the Tribe’s 11 county service area and have a current update on file. These funds are intended for Tribal Members who are not eligible for Purchased Referred Care.
Dental and Medical is $2000.00 annually combined.
All benefits are subject to funding availability. When calling for pre-authorization PRC will authorize for household members only, and voice messages do not hold funds, the individual must speak to PRC Staff and obtain an Out of Area (OOA) number to secure funds. If you are not already registered for health services, please call anytime to request an application via email or regular mail.
Pharmacy, Cataract Surgery, and Hearing Aid benefits are available in addition to the annual benefit of dental and medical. Vision benefits are available every other year with the exception of annual benefits if you are an elder, child or student or have been diagnosed with diabetes.
- Pharmacy $500.00
- Vision $450.00
- Hearing Aid or Cataract Surgery $2000.00
Note: Hearing aids will be authorized no more than once every 3 years.
Prior authorization is required to access all of your benefits except pharmacy. You can call in any time to access your OOA Benefits. The authorization will be valid for the calendar year 2023. The benefit does not roll over to the next year.
Call PRC at 541-444-9677 and leave a message.
Please Send Claims with W-9 by:
Fax 541-444-9645
Or by mail:
SCHC Attn: Siletz Purchased/Referred Care
P.O. Box 320
Siletz, OR 97380
Caremark (Pequot) Pharmacy Card & Reimbursement Information
Regardless of where you live, your pharmacy benefit is $500.00 per year. Every January 1st your card renews. Members that live in the 11-County Service Area should have your maintenance medication mailed to you through the Siletz Community Health Clinic (SCHC) pharmacy. Not all medications are in the SCHC formulary, so that is when you would use you pharmacy card at a retail pharmacy such as; Walgreens, Fred Meyer, Rite Aid etc. . . .
Members that live outside the 11-County Service Area (Direct Care) are not able to get medication mailed through the Siletz clinic, but are able to get medication directly through Pequot Pharmacy. Any maintenance medication needed by Direct Care patients should be mailed to Pequot directly this will stretch your card dollars.
Patients that have primary pharmacy insurance, such as Medicaid, Blue Cross Blue Shield, AETNA, Medicare Part D etc… and have to pay a co-pay up front to the retail pharmacy, can be reimbursed up to the $500.00 per year. Members that pay up front for medication, and still have a balance on their pharmacy card, can be reimbursed as well.
To receive a reimbursement you must provide the receipt from the pharmacy, not the cash register receipt. The receipt must have: Your Name, Dr. Name, Date of Service, Medication Name, Medication Dosage, Amount Paid. Mail your receipt to
Purchased Referred Care
PO Box 320
Siletz, OR 97380
Your pharmacy card should not have you Social Security number on it. If the card has your Social Security number on it, then you need to contact Selina Rilatos with PRC at 541-444-9677 to get a new card, or email her at SelinaR@ctsi.nsn.us. You will be required to have an updated Individual Registration form on file in order to receive your new card.
You can fill out the Reimbursement form linked above and send it directly to Pequot if you would like. If you need assistance in filling it out, you may send it to PRC staff for help. Please note that it may take longer to receive reimbursement if you send it to PRC staff first.
Mental Health Services
Services Available
- Counseling Services – individual or family
- Psychiatry Services
- Psychology Services
- Up to 8-visits annually (more if medically necessary)
Eligibility
Siletz Tribal Members are eligible for Purchased/Referred Care (PRC), formerly Contract Health Services (CHS).
How to Get Benefits
Call PRC at 800-628-5720. Prior to making an appointment with a provider, confirm the provider will accept PRC as payment. Benefits are limited and on a first-come, first-serve basis.
What You Need to Know
After calling PRC for benefits, the patient will receive a letter with program details. The letter also provides information that the patient can give to their provider for payment processing information.
You will not be required to use other resources first. This will allow you to go to a provider that does not accept Oregon Health Plan/Medicaid or your private insurance.
Also Available for Siletz Tribal Members
Medicare Reimbursement
The Siletz Tribe reimburses any Siletz Tribal member for their Medicare B (Hospital) and D (Pharmacy) premiums.