The Confederated Tribes has contracted with the Indian Health Service (IHS), an agency of the U.S. Public Health Service under the Department of Health and Human Services, to operate and manage the Purchase and Referred Care (PRC) Program. The PRC Program allows the Confederated Tribes to authorize and pay for health-related services for Tribal Members in the five county service area. The PRC program is funded each year through the IHS after it receives funding provided by the United States Congress.
The PRC Program is not:
- An Entitlement Program (such as Medicare)
- An Insurance Program
- An Established Benefit Package
PRC is a payer of last resort. All alternative resources (i.e. Oregon Health Plan, Medicare, private insurance) must be used first and PRC will pick up any remaining patient responsibility for approved and eligible claims. Authorized payments are based on clearly defined guidelines and eligibility criteria and subject to availability of funds. Your Tribe or IHS cannot guarantee that funds are always available.
CTCLUSI enrolled Tribal members residing in the Tribes’ five-county Service Delivery Area (SDA) in Oregon Coos, Curry, Douglas, Lane and Lincoln counties. Must submit an initial application and then re-apply annually. Must submit any changes in address, phone number and/or insurance/alternate resource coverage as soon as possible after the change.
- Tribal members who move into the SDA become eligible after 90 days but must submit proof of permanent residency in the SDA (copy of lease/mortgage document and two additional proof of residency required).
- Upon moving out of the SDA, Tribal members remain eligible for PRC for 180 days, after which any further PRC requests will be denied.
- A non-Indian woman pregnant with the child of an enrolled CTCLUSI Tribal member residing in the five-county SDA is eligible for pregnancy-related medical care through delivery and the 6-week post-partum check-up (subject to DNA testing of the child within 1 month of birth to prove eligibility).
- Newborn children of eligible Tribal members, residing in the SDA, will be eligible for newborn medical services up to six months of age upon completion of a Tribal enrollment application, PRC application, DNA testing proving parentage of the Tribal member and approval by the Enrollment Coordinator.
- Students who reside in the SDA prior to leaving for school will remain eligible for PRC through their course of study, independent of the location of the school. If the student does not return to reside within the SDA after completion of school, he/she will remain eligible for PRC up to 180 days after graduation/completion, after which further request for PRC will be denied.
Eligible CTCLUSI Tribal members who are eligible for Medicare, Part B and Part D, will be reimbursed for the monthly cost of these items. Not eligible for retroactive reimbursement.
Many Tribal members ask why they need a purchase order (PO) to see a doctor and why we ask so many questions when they call for a PO. Purchase orders play an important role in determining what PRC can and will pay for. A PO is an authorization for you to see a doctor BUT it is NOT a guarantee of payment. When you call for a PO you will be asked provide the following information:
1. Name of the provider (doctor and/or clinic name)
2. Date of the visit, and,
3. Reason for the visit. PRC cannot issue a PO without this information.
You must get a PO for EACH provider you see.So, if your doctor refers you to another doctor or sends you for tests, you will need to call for a PO for that visit, too.
Payment will be denied for any visit without a PO. In general, you need to get a PO BEFORE you see the provider. The only exception to this is for emergency care and hospitalization: you must notify CTCLUSI Purchase and Referred Care within 72 hours of emergency treatment or admission to a non-IHS hospital. Elders 65 years and older have thirty (30) days for notification. When you call for a PO and we ask you to give us a reason for the visit, we ask because PRC does not pay for some types of care. We need to know the purpose of the visit so we can determine the priority level. For example, if you are going to see a doctor to have a face lift, that procedure is an excluded service (see the discussion on Medical Priorities in the next section). We will not issue a PO because PRC cannot pay for excluded services. We also have limits on certain types of services, such as chiropractic care, physical therapy, vision care, and dental care. When you call for a PO we can let you know if you are close to exceeding your limit. We cannot issue a PO without a reason for the visit.
1.Prior Approval – You, or someone acting on your behalf, must get prior approval for any non-emergency treatment you receive. A purchase order will be provided to give to your healthcare provider. If the claim has no assigned purchase order, the claim will be denied and you will be responsible for the amount owed.
2. 72-Hour Notice – When you receive emergency outpatient treatment you, or someone acting on your behalf, must notify PRC within 72 hours in order for the claim to be considered for payment. If this is not done, PRC will deny payment for the claim.
3. Denial and Appeal Letters – If you are denied PRC, you will receive a letter from our office explaining the reason. You have the right to appeal in writing within 30 days to the Tribal Health Director.
4. Out-of-Pocket Expenses – IHS does not allow us to refund Tribal Members directly for out-of-pocket expenses. Exceptions will no longer be made to this rule. An example would be prescriptions for eyeglasses that are filled at Costco. Costco will not bill us directly and, therefore, we cannot pay them directly. If you choose to have your eyeglass prescriptions filled at Costco (or any other provider who will not bill PRC) you may do so; however, PRC will be unable to reimburse you for these costs.
5. Provider Updates - When you make your appointment, confirm with them that they will bill PRC, after billing any insurer you have (i.e., Shasta, Medicare, etc.) When you arrive for your appointment, please be sure that they have all of your current insurance information. This will help expedite your claims for processing and payment.
You can help PRC stretch your Tribal dollars by following the guidelines below:
1. Use the emergency room for emergencies only. An ER visit costs many times more what a visit to the doctor’s office would be. If your condition is not life-threatening it would be appreciated if you would contact your doctor’s office during regular business hours.
2. Establish yourself as a patient with a physician, so that in an emergency you have a doctor to call before resorting to the emergency room.
3. Fill prescriptions with generic drugs when they are available. We will have to start requiring pre-authorizations for brand name drugs if we cannot control these costs.