PURCHASE REFERRED CARE (PRC)
OUTSIDE REFERRALS PROCESS
The Purchased Referred Care (PRC) program is a Federal program funded by Indian Health Services. This program is an addition to all other health resources for which a patient is eligible, such as government or private insurance. Its purpose is to help Tribes and their Tribal Citizens improve their health or continue their necessary medical care by lessening the financial burden on the eligible patient. A referral is given when a medical provider deems it necessary for a patient to receive medical care outside of what is offered at our health clinic.
PRIORITY LEVELS
Seeking treatment? Know what priority level your treatment falls under to ensure it is included:
PRIORITY ONE
Emergent, acutely urgent care, diagnostic or therapeutic services that are necessary to prevent death or serious impairment of health.
PRIORITY TWO
Preventative Care Services not offered within the PCI Health Clinic. A preventive care service is health care that is aimed at the prevention of disease or disability.
PRIORITY THREE
Treatment of illnesses or conditions that have a significant impact on the patient’s ability to live a healthy lifestyle. This includes services that are not available at the Clinic and require specialty consultation.
Services or conditions not covered by the PRC program include, but are not limited to:
Elective surgery
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Cosmetic procedures
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Treatment deemed experimental or investigative, or have no proven medical benefit
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Second opinions
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Durable Medical Equipment (DME)
REFERRAL PROCESS
Your PCI health care provider has determined that you are in need of health care services that are currently not available at the PCI health department. The following offers clarification for the “next steps” in the referral process:
- Your referral specialists receive referral information from your medical provider. The medical provider and Business Office decide if your referral will be covered
(copays and deductibles) by the PRC program. - Your medical provider or nurse will direct you to the referral specialist’s office to get information about scheduling your outside appointment. It is extremely important to provide a current phone number to reach you after scheduling your appointment.
- The referral specialist will begin the process by scheduling your appointment with a specialist of your choice. You will be contacted by phone or phone message of your appointment date and time. If you have to reschedule the appointment, please call the specialist’s office directly to reschedule, then call the Business Office (extensions 2317, 2324) to have the new date and time updated on your referral.
- After you have been called and informed about your specialist appointment, you must pick up your referral from the registration window at the PCI Health Department to take with you to your appointment.
If you have not been contacted within two weeks by the referral staff with further information regarding your appointment, you are encouraged to call the Business Office (extensions 2317, 2324).
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If the specialist schedules a follow up appointment or further appointments for testing, procedures, or surgery, please contact the Business Office (extensions 2317, 2324) with the date and time of your new appointments.
GENERAL RULES
If any type of medical care is obtained without following the proper referral process, the payment for that service will not be covered and payment will become the responsibility of the patient.
All doctor appointments must be scheduled through our health clinic first before receiving a paid referral to a specialist.
Indian Health Services guidelines allow the Purchase Referred Care Program pay only after all other resources have been exhausted. If the patient has other health insurance it must be used first before the PRC program can provide payment for a referral. If the patient does not have primary insurance coverage, he or she will be referred to the Resource Coordinator for help in applying for health care resources.
Please call (251) 368-9136 extension 2324 for help with your medical insurance needs.
72 HOUR NOTICE
The Purchased and Referred Care program also covers inpatient hospital stays and emergency room visits. To initiate the process, a patient must follow the process below:
All hospital related admissions require that the Business Office receive notification within 72 hours of admission, by either the patient or immediate family member.
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Please call (251) 368-9136 extension 2317, 2324 with your hospital name, date of admission, and general reason for the your admission.
