CONTRACT HEALTH SERVICE HAS NEW NAME-PURCHASED REFERRED CARE
Indian Health Service has changed Contract Health Service Name to Purchased Referred Care (PRC) to most reflect what services are provided. This change was made recently at the federal level and tribes have been notified of this change within the last few months.
PURCHASED REFERRED CARE (Formerly CHS) MISSION STATEMENT
Purchased Referred Care-PRC (CHS) mission is to provide appropriate access for Sault Tribe Members to achieve high quality care beyond what is available through Tribal Health facilities. PRC will work within financial resources and will clearly communicate its program and services to Tribal members.
WHAT IS PURCHASED REFERRED CARE (Formerly CHS)?
Purchased Referred Care benefits are established by Federal law and regulations and funded through appropriations from the Federal Government. Tribes establish priorities of coverage based on funding appropriated as to what services they are able to provide to their members. Members should not rely solely on PRC for their medical coverage. If members are eligible for an alternate resource such as Medicare, Medicaid, MI Child/Healthy Kids, VA, employee sponsored insurance, etc. they should apply for those programs. PRC is the payor of last resort. PRC may be used as a secondary payor should there be a primary insurance on a “covered service” authorized by PRC to pay.
WHO IS ELIGIBLE?
Sault Tribe members residing within the (Purchased Referred Care Delivery Area) as established by the Federal Government. Non Indian dependents covered for pre and post natal care and delivery, for communicable disease. Tribal members must apply for PRC and be a permanent resident of the PRC Delivery Area. PRC service area consists of seven counties: Mackinac, Chippewa, Luce, Schoolcraft, Delta, Alger, and Marquette.
PRC (formerly CHS) Eligibility Requirements
Sault Tribe members residing within the Purchased Referred Care Delivery Area must have a completed application on file and approved for PRC prior to PRC paying for a service deemed covered outside of our Tribal Clinics. The applicant must provide proof of income, such as current 1040 tax return, and proof of residency. Proof of residency would include copies of driver's license, utility receipts, voter registration, etc. Applicant must be enrolled in PRC 90 days prior to PRC assisting with an Inpatient Stay. Proof of income is used to determine eligibility for alternate resources. If members are eligible for an alternate resource, such as Medicaid, Medicare, health insurance provided by employer, VA, etc. they need to apply for those programs. PRC is the payor of last resort. PRC may be used as a secondary payor for any copays or deductibles on a "covered" service authorized to pay by PRC.
Sault Tribe Eligible PRC Member's Responsibility
It is the member (patient) responsibility to request assistance (prior authorization/voucher) by contacting PRC office directly for all services not provided at our Tribal clinics in which they are requesting assistance. PRC staff will determine member’s eligibility for the program at this time. The request for assistance should be done prior to the service being provided unless it is an emergency visit that occurs after hours or on the week-end when Tribal clinics are closed, then members must report this to PRC within 72 hours of the event. An emergency room report/physician notes will be reviewed to determine priority to determine if service will be covered by PRC.
*It is the member’s responsibility to call PRC-Purchased Referred Care for their voucher for all out of clinic services, not the referral coordinators at each clinic site. They set up your referral appointments to the outside providers that your clinic provider is referring you to. PRC Staff determine if the referred care is a covered service based on funding and established priorities of coverage for that fiscal year. Referrals are marked by Categories, Priority 1A, 1B, 2, 3, 4, 5 by the clinic providers based on guidelines set up by Indian Health Service. There may be extenuating circumstances where the provider requests Special Committee Review. The committee consists of Medical Director, Clinic Manager, Health Director, Nurse supervisor, PRC Manager who meet bi-weekly.
PRC (formerly CHS) Staff and Contact Information
PRC-Purchased Referred Care contact phone: 1-800-922-0582 or 906-632-5220, PRC office is located on the 3rd floor of Sault Tribe Health & Human Services Bldg., 2864 Ashmun St., Sault Ste. Marie, MI 49783. Our Mailing office is: Purchased and Referred Care, PO Box 1628, Sault Ste. Marie, MI 49783.
Tina Fox PRC Utilization Manager
Carol Pages-Montie PRC Certifier
Kim Menard Patient Care Coordinator (A-G)
Nicole McKechnie Patient Care Coordinator (H-N)
Claudette Crook Patient Care Coordinator (O-Z)
Fiscal Year 2015 Oct 1, 2014-Sept 30, 2015
Priority 1A, 1B
Priority II Diagnostics, Consultations-1 visit with surgery notes to be reviewedPriority III-Common Exception List as approved by PRC Review Committee