Tribal offices reopen September 1st with many COVID safety protocols still in place. Read more here.

Purchased/Referred Care (PRC)

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.

Hours

Monday through Thursday
8:00 AM – 4:30 PM

Friday
9:00 AM – 4:30 PM

Contact

Pre-authorization and notification within 72 hours is required.

541-444-1236
800-628-5720
Fax: 541-444-9645

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

PRC Tech I

Joell Strong

PRC Tech II

Heather Warren

PRC Tech II

Christine Knott

PRC Tech II

Purchased/Referred Care Updates

Updated Hours

PRC will be open to calls:

8 AM – 11 AM and 2 PM – 4:30 PM

PRC will be closed for calls during Admin time between 11 AM – 2 PM for lunch, team meetings, and to process claims. During Admin time and after hours, calls will go to the PRC voicemail and will be processed accordingly.

For Voicemails

Need an Authorization Number

Your message should include:

  • Your name
  • Your date of birth
  • Your phone number
  • Provider or facility name and type of appointment (dental, medical, optometry, etc.)
  • Date of appointment

PRC staff will call you as soon as possible with the goal of same day but no more than 1 business day.

PRC general questions or status of claim

Your message should include:

  • Your name
  • Your date of birth
  • Your phone number
  • Reason for call

PRC staff will call you as soon as possible but no more than 3 business days.

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.

Alternate Healthcare Benefits

Alternate healthcare benefits are available to all enrolled Siletz tribal members. We do request that you have completed an individual registration application and are updated with the Siletz Community Health Clinic before obtaining authorization for alternate healthcare benefits.

The benefits that are available include:

  • Acupuncture
  • Chiropractic Care
  • Massage Therapy
  • Naturopath Services

Each patient is eligible for a maximum of three visits up to $75.00 per visit, per day, per quarter. Anything over that becomes the patient’s responsibility. These benefits are on a first come first served basis and are available four times per year at the beginning of each quarter as long as funding is available. Patient will 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 how to bill PRC.

Tribal Council Expands Alternative Healthcare

Tribal Council approves Naturopath services. In addition to acupuncture, chiropractic, and massage services, tribal members now may use the alternative healthcare funding to access naturopath services.   The program remains the same: up to $75 per visit for a maximum of 3 visits per quarter. Contact PRC for more information; it may take a few days to get a response due to current staffing challenges.  Thank you for your patience and kindness as we work through these challenges. 

Dental Services are Eligible for PRC Payment Even if You Live Near the Siletz Clinic or an I.H.S. Facility

PRC-eligible patients (tribal members, dependents, pregnancy) living within 40-miles of the Siletz clinic or an I.H.S. facility are now eligible to obtain services at an outside dental facility.   Due to safety measures taken in response to Covid-19, the Siletz dental department operates a reduced schedule, which impacts the ability to serve all tribal members wanting oral care.   PRC eligible services will be the same types of services you would be eligible for at the Siletz clinic or another I.H.S. facility.  You do not need a referral, but you will need to call PRC for an authorization number.

If you are unsure if specific dental services will be paid, please contact PRC.

Optometry Access Temporarily Expanded

Due to access concerns, you may see an optometrist outside of the Siletz Clinic or I.H.S. facility for as long as the Clinic remains in Phase I.

PRC-eligible patients living within 40-miles of the Siletz clinic or an I.H.S. facility are now eligible to obtain services at an outside optometry facility.  Your annual/bi-annual benefit applies.  Please contact PRC for additional information.

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.

 

2022 Out of Area Benefits

The Tribal Council has approved Out of Area Benefits for 2022. These benefits are for Tribal members who live outside the 11-county service area. To qualify, Tribal members must be registered for health care with the Siletz Community Health Clinic. These funds are intended for Tribal members who are not eligible for Purchased/Referred Care and reside outside of the Tribe’s 11-county service area.

All Benefits are Dependent on Available Funding:

Annually Biannually

$2000 Total in Medical + Mental Health + Dental + Hearing

Plus $500 Pharmacy Card Benefit

$450 in total Vision Care for Adults*

*available annually for Elders, Children, Students or People with Diabetes

 

Prior authorization by PRC is required and benefits must be used within the authorized quarter. Any funds not used within 90 days, or claims not received, will be returned to the pool for redistribution. An individual may access benefits up to $2,000 annually by calling during the desired quarter. For example, an individual may call in January for medical of $500 and then call again in November for dental of $1,500 for a total of $2,000. All benefits are subject to funding availability. When you call for pre-authorization, PRC will authorize for household members only. The individual must obtain an authorization number for each Out of Area (OOA) service to secure funds.

To Authorization for can only be given for the quarter we are currently in;

1st Quarter | January – March

2nd Quarter | April – June

3rd Quarter | July – September

4th Quarter | October – December

All providers must submit their claims with W-9 via fax to 541-444-9645 or by mail to:

SCHC
Attn: Siletz Purchased/Referred Care
PO 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 fill out the Pequot Reimbursement Form and submit it with the requested documentation detailed on the form.

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 PRC at 1-800-628-5720 to get a new card. You will be required to have an updated Individual Registration form on file in order to receive your new card.

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.

Learn More