Purchased/Referred Care (PRC)
Fax: (707) 236-8921
Purchased/Referred Care (PRC) is a restricted Federal Program of managed care for a limited population. It is designed to provide for the payment of a limited number of services not available at our clinic, according to levels of care. SCIHP currently covers levels I through III only, when it is determined to be medically necessary. Patients should note that most Level II services and many in Level III are available directly from SCIHP. At the present time, inpatient hospital care is not a covered benefit.
In order to qualify for Purchased/Referred Care, you must meet specific requirements. In general, you must
When a SCIHP physician, dentist, or other authorized provider makes a referral to an outside consultant or service, such a referral within itself does not constitute a commitment for payment by SCIHP PRC. Prior approval must be obtained from PRC.
Denial and Appeals
In the event it is necessary to deny payment for outside care, a denial letter is formally issued by Purchased/Referred Care (PRC), which states the reason for the denial and the procedure for appealing the decision. You are allowed thirty (30) days from the date of the denial letter, to appeal in writing to: Sonoma County Indian Health Project, Inc., Attention: Chief Executive Officer, 144 Stony Point Road, Santa Rosa, CA 95401. This constitutes the final action available to you.
The principal reasons for denial of payment are:
1. Ineligible for Purchased/Referred Care services (i.e., no documentation of Indian descendancy or does not meet residency requirements, etc.).
2. Failure to obtain prior approval (patient referral) for non-emergency services, i.e. no referral issued from SCIHP Provider.
3. Failure to provide notification to the PRC Program after receiving emergency care.
4. Failure to comply with all regulations regarding an alternate resource for which the patient may be eligible (i.e., refusal to apply for Medi-Cal,
5. Over Property/over income Medi-Cal denial letter is expired or was not submitted.
6. All bills must be submitted to PRC, within 180 days from the date of service. Any bills received after the 180 days, will not covered by SCIHP and remain the patient’s responsibility
7. Service requested is not within the established levels of care, such as in-patient hospitalization.
8. Not an established / active patient of SCIHP at the time services were provided.
The PRC Program is neither an entitlement program nor an insurance program. By federal law and regulation, it is the payer of last resort as indicated earlier. This simply means that if a PRC patient is also eligible for another health financial resource, they are required to take advantage of that program before PRC funds can be authorized to cover payment for outside services.
Questions or Concerns
Please refer to the Purchased/Referred Care Services/FAQ’s brochure for more information. You may contact Purchased/Referred Care Services by calling (707) 521-4634 or (707) 521-4539 for any questions.
PRC Frequently Asked Questions
Sonoma County Indian Health Project, Inc.
Attention: Purchase Referred Care (PRC)
144 Stony Point Road
Santa Rosa, Ca 95401