Purchased and Referred Care Program

Purchased/Referred Care

Purchased/Referred Care (PRC) is a restrictive program and not a comprehensive program. It is not an entitlement program or an insurance program and operates as funds are available. It is designed to provide for the purchase of a limited number of services not available at our clinics.

Scope of Program

The PRC Program has guidelines set forth that determine services which it may pay for. In general, PRC may pay for specialty physician services and other authorized health care support services for eligible PRC patients.

Eligibility

In order to qualify for PRC you must meet certain Federal requirements. In general, you must be screened by PRC Staff for the following:

First, patients must provide documentation proving they are American Indians from native California tribes, or non-California Indians from federally recognized tribes currently living on reservations in California.

Second, patients must reside within Toiyabe’s service area.

Patients must complete Toiyabe’s PRC application process.

Applicants eligible for other types of healthcare resources such as Medi-Cal and Medicare must utilize these options prior to seeking PRC support. The PRC program is through Health and Human Services’ Indian Health Services and is considered by mandate to be the payer of last resort.

You will be asked to be rescreened for PRC every six months or sooner in the event of status change. In the event you fail to fully complete the application process, (including follow-through with the alternative resources), you will be automatically denied eligibility.

Newborns

If a newborn requires a referral and the parents are PRC eligible, then the PRC Program can extend services to the newborn for up to 2 months without a registered birth certificate.

Referral Process

If an eligible person requires care that is not available at Toiyabe, a referral is made to an outside provider.

All referrals must be initiated by a Toiyabe provider.
Once referred, the patient must verify their eligibility for the program with PRC staff.
The PRC staff are the only ones that can authorize payment for health care outside TIHP.
Pre-authorization is required for all non-emergency services and follow-up care.
All emergency services must be reported to the PRC staff within 72 hours after services have been provided (30 days for elders 55 years of age or older and disabled persons.)

Examples of Services Not Covered

Services or supplies that are related to a condition not within established medical priorities.
Nursing home care.
Personal comfort and / or convenience items.
Sterilization that does not meet IHS regulations.

Common Reasons for Denial of PRC Coverage

Eligibility
The patient failed to obtain prior approval from PRC for non-emergency services.
The patient failed to notify PRC within 72 hours (or 30 days for elders 55 years of age or older and disabled persons) after seeking emergency services.
Services not within the level of cares funded
Services being denied from alternative resources, (i.e., private insurance, Medi-Cal, Medicare, etc.) due to failure of completion from patient responsibility
Patients who refuse to use alternative resources or be screened for alternative resources.

Appeals

If a person is denied payment for care, the PRC program issues a denial letter. The letter of denial states the reason for denial of payment and explains the rights of appeal. The person has 30 days from receipt of a denial letter to appeal.

Remember

It is important to remember that only PRC staff can authorize payment for care. You must verify with PRC that your referral is approved before.

All referrals must be made by a Toiyabe Provider and does not guarantee PRC payment
PRC is a payor of last resort and does not guarantee payment for all services
It is the patient’s responsibility to check with the PRC department to verify if their referral was approved.
Failure to apply for alternate resource will result in denial for PRC services.
PRC staff are available to assist you with any and all PRC questions/process.
To assist the PRC staff in processing payments, please bring in Explanation Of Benefits (EOB) and any bill(s) for referred services.
If referred to an outside provider and that provider is referring you to a different provider, you must have all clinic notes sent to your Toiyabe provider for PRC to review coverage.

For more information on how you may benefit from this extraordinary program at Toiyabe Indian Health Project, please call 760-873-6111; or visit our Bishop Clinic and request a consultation with a PRC representative.

Call 760-873-6111

Download the complete Purchased and Referred Care Program brochure.

This is strictly for Administrative questions, for any sensitive information or patient needs contact the appropriate department for discussion.