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Purchase/Referred Care (PRC) Users Guide

 The Siletz Tribal Health Department is a program of the Confederated Tribes of Siletz Indians. It is operated under a compact agreement between the Tribe and Indian Health Services (IHS), an agency within the U.S. Department of Health and Human Services.

The program serves over 5000 Siletz Indians throughout the 11-county service area in Oregon. Through PRC the Siletz Tribe can buy services that are unavailable at the Siletz Clinic or other IHS facilities.

  • The PRC program is funded each year by the United State Congress, where it is determined how much money is to be made available.
  • The PRC program in not:
    • an entitlement program (such as Medicare)
    • an insurance program
    • an established benefit package
  • PRC payments are based on clearly defined guidelines and eligibility criteria. Level of care is subject to the availability of funds. Depending upon expenditures throughout the year, there is no guarantee that funds will always be available, especially towards the end of the year.
  • PRC payments are intended to help pay for health care when no other source of health care payment is available. PRC also supplements alternative resources after they have been utilized. The use of alternative resources enables the Tribe to provide more and better health care for Siletz people.
  • Payment for health care outside a tribal or IHS facility can only be authorized by PRC staff members. No one else can authorize payments.

Services

Purchased/Referred Care pays for medical and dental services that tribal or IHS facilities are unable to provide. PRC is used in situations where:

  • No tribal or IHS direct care facility exists within a 40-mile radius of the patient’s residence.
  • An IHS or tribal direct care facility cannot provide the required emergency or specialty care.
  • A patient’s alternative resources are not enough to cover the total cost of required care.
  • The service is determined to be within established medical priority

Eligibility

You are eligible for PRC services through the Siletz Tribal Health Department if you have registered through Purchased/Referred Care or the Siletz Clinic and/or updated that registration within the past year, and

1. You are an enrolled Siletz tribal member, or a minor dependent through age 18 of an enrolled member and

  • Reside within the Oregon eleven-county service area of: Lincoln, Tillamook, Marion, Polk, Yamhill, Linn, Lane, Benton, Multnomah, Washington, and Clackamas counties. This is called the Siletz Purchased/Referred Care Delivery Area (SPRCDA).
  • You may be away from the SPRCDA and still be eligible for PRC if you are a full-time student, foster child, or transient (migratory/seasonal worker), or you have left the SPRCDA less than 180 days before the date of service.

2. Other eligible persons are:

  • A non-Indian woman pregnant with a PRC eligible Siletz Tribal member’s child and residing within the SPRCDA. If you are not married to the father of your child, he must verify he is the father with a notarized written statement.
  • A non-Indian member of a PRC eligible Siletz Tribal member’s household, if the Health Director determines that services are necessary to control a public health hazard.
  • A minor, non-Indian dependent, foster child, or step child of a PRC eligible Siletz Tribal member. A copy of adequate proof must be provided, i.e. marriage certificate, birth certificate, tax return, guardianship, or foster care placement order.
  • A member of a federally recognized tribe who resides on trust land within the SPRCDA.

Alternative Resources

Alternative resources are other resources of health care or health care payment available and accessible to you. PRC is the payor only of last resort. If you have questions, contact Purchased/Referred Care.

You are required by federal regulation (42 CFR, Ch1, Subpt 36.23F) to apply for an alternative resource if there is reason to believe that you may be eligible. If you are eligible for an alternative resource and you refuse to apply for or use that alternative resource, you will not be allowed to use PRC. You do not have to use your own financial resources, or sell valuables and property to qualify for alternative resources.

Some examples of alternative resources include:

  • Medicare (Part A, Part B)
  • Medicaid/ Oregon Health Plan
  • Veteran’s Benefits (Champus, Champva)
  • Crippled Children’s Services
  • Children’s Rehabilitative Services
  • Private Insurance
  • State Maternal & Child Health Programs
  • Auto Insurance
  • Victim’s Assistance Program
  • Workmen’s Compensation
  • State Vocational Rehabilitation
  • School Insurance
  • Home Owners Insurance

If you are a student and your grant includes funds for health services, you will be expected to use the grant funds to purchase available student health insurance.

Often it is to your advantage to sign up for these types of programs. Frequently these alternative resources can pay for or be a source of health care services that the PRC program cannot provide.

Patient’s Rights & Responsibilities

As a patient, it is your responsibility to register and update your registration annually through the Siletz PRC office or the Siletz Community Health Clinic. Through registration, your eligibility for “Direct” and PRC services is determined, and potential or established alternative resources
are identified. You will need to provide proof of your Indian descent when you first register, and you may be asked to provide proof of residency.

Prior Approval – You or someone acting for you must get prior approval for any non-emergency treatment you receive that will require PRC funds for payment.

72-Hour Notice – When you receive emergency treatment from an Emergency Room or Urgent Care, or are admitted to a non-IHS facility, you must notify a PRC staff member within 72 working hours. PRC closely monitors the use of hospital emergency room services and urgent care. A 24 hour on-call medical professional is available to assist you in determining whether your symptoms require immediate attention. To reach the person on-call, use the PRC or Clinic telephone numbers, an answering service will direct your call.

Denial and Appeal– If you are denied PRC payment, a letter from the PRC program will explain the reason. You have the right to appeal if you do so in writing to the Health Director within 30 days from the date of the denial letter. The Health Director will review your case and respond in writing. If the Health Director denies your appeal, you have the right to appeal to the Siletz Tribal Health Committee by writing to them within 30 days from the date of the response from the Health Director. If your appeal is again denied, you have the right to appeal to the Siletz Tribal Court, whose decision is final.

The most common reasons for denial are:

  • You did not call PRC within 72 working hours following an emergency room or urgent care service.
  • You did not supply appropriate proof of Indian descent or you live outside the PRCDA and are ineligible for PRC services.
  • Request for specialty care services did not meet the level of care requirements of the Gatekeeping Committee at their review.
  • You did not obtain prior approval for non-emergency service by calling a PRC staff member for a pre-authorization number.
  • You did not apply for potential or established alternative resources or did not use the resources you had available.
  • Medical review of you emergency room report did not support the necessity for using the emergency room.

Tips for PRC

Each PRC staff member handles a different part of the alphabet (A-G, H-O, and P-Z). When you call, ask for the PRC technician who handles claims for the first initial of the last name of the patient (i.e. John Doe, ask for technician who handles claims for “D”). In the future, ask for that
staff member by name. If your PRC technician is unavailable, leave a message stating patient’s name, phone number, and reason for the call.

Call and ask for an authorization number as soon as you know the date of an upcoming appointment. Specialty care may require review and approval by the Gatekeeper Committee, so allow plenty of time for this process.

Call in each appointment. Each appointment requires a new authorization number. Always ask and keep a record of the authorization number, even if someone calls in for you (such as a nurse at the Clinic).

Keep your authorization numbers on your calendar next to your appointment date and time.

If you have insurance, PRC is not able to authorize payment until after the insurance has responded. They will send you a statement (called an Explanation of Benefits (EOB)) explaining what they paid and the balance still owed. Send a copy of that statement to PRC so that we can
pay the remaining balance.

To update your eligibility annually, or when you have a change in name, address, phone number, or insurance, you may:

  • Download the registration/update form and print it
  • Contact PRC and ask them to mail you a form
  • Pick up a form from the Siletz Clinic’s front desk

Complete and sign the form, and return it to PRC either by mail, fax, or in person.

Contact Information

Address
PRC
200 Gwee-Shut Rd.
PO Box 320
Siletz, OR 97380

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