Health care can be difficult to understand and to navigate and we know that. This month, Circle of Health is continuing its series of articles to help take the confusion out of health care so that you may be empowered to take control of your own health care.
What is PRC? PRC is Purchased/Referred Care. Purchased/Referred Care is a federally funded program designed to provide comprehensive health care services to American Indians and Alaska Natives.
The Indian Health Service recognizes that many local tribal clinics cannot provide all the services a patient may need.
The general purpose of PRC is for IHS and tribal facilities to purchase services from private health care providers in situations where: 1) no IHS or tribal direct care facility exists; 2) the existing direct care element is incapable of providing required emergency and/or specialty care; 3) the local need for medical services exceeds the existing local clinic staffing.
Since Purchased/Referred Care is not a program where the government fully pays for Indian Health, the supplementation of alternate resources (e.g., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible American Indian/Alaskan Native.
This means that a patient must have health insurance, or put forth a good-faith effort to obtain health insurance, before the PRC program can help pay for medical costs.
You are eligible for PRC if:
You are a member or descendent of a federally recognized Tribe, or have close ties acknowledged by your tribe.
You live on the reservation or the defined CHSDA (Contract Health Service Delivery Area). Currently, the CHSDA is Aitkin, Kanabec, Mille Lacs and Pine Counties.
You get prior approval for each case of needed medical services or give notice within 72 hours.
Payment may be approved if:
The health care or service you receive is medically necessary, and
The service is not available at an accessible IHS or Tribal facility, and
The facility’s PRC staff determines that your case meets current medical priorities of the facility.
PRC funds are available and sufficient to pay for the services.
Approval, Billing, and Payment:
You must have primary insurance, or be willing to apply for any alternate resources for which you may be eligible.
A PRC purchase order is issued to a provider authorizing payment for services.
IHS or Tribal staff and the authorized provider will coordinate your medical care.
The provider will bill and collect from your primary insurance or resource.
The provider will bill any unpaid balance to the PRC program.
The IHS is the payer of last resort and requires patients to exhaust all health care resources available to them from private insurance, state health programs, and other federal programs before the PRC program can provide payment. The PRC program continues to negotiate contracts with providers to ensure competitive pricing for services provided, in spite of the limited number of providers available in many rural communities.
If you have questions regarding Purchased/Referred Care, contact Rosanne Molitor at 320-532-4163, extension 2538.