Purchased Referred Care

Purchased/Referred Care (PRC)

Phone (707)565-1043 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.

  • I. Emergency/Acutely Urgent Care

  • II. Acute Primary& Preventive Care

  • III. Chronic Primary & Secondary Care

  • Eligibility

    In order to qualify for Purchased/Referred Care, you must meet specific requirements. In general, you must

    • Provide documentation that you are an American Indian from a federally recognized tribe that is native to California (i.e. California Native).

     

    • Apply for all alternate health resources for which you may be eligible, such as private insurance, Covered California, Medi-Cal, Medicare, California Children’s Services. Our Certified Enrollment Counselor is available to assist you in this process and answer any questions you may have. SCIHP is always the payer of last resort only.

     

    • Be a current active patient of SCIHP and have a SCIHP provider designated as your Primary Care Provider (PCP) on your private insurance at the time outside services are rendered.

     

    • Have a current referral on file with PRC.

     

    • Notify PRC of all Emergency Room or Urgent Care visits within 72 hours of the visit.

     

    • Elders (Age 55+) and/or disabled eligible members have 30 days to notify PRC after the emergency.

     

    • Non-emergency services must have a referral issued from a SCIHP provider from either medical, dental or behavioral health.

     

    Referral Process

    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.

    Summary

    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) 565-1043 for any questions.

    PRC Frequently Asked Questions

    1What is Purchased/Referred Care?
    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 limited services not available at SCIHP.
    2I am Native American, why do I need to get Medi-Cal or other insurance?
    The PRC funding for payment of outside services is limited. Therefore, all patients are required to apply for Medi-Cal or any other available coverage. SCIHP is always the payer of last resort
    3The doctor gave me a referral, doesn’t that mean the clinic will pay?
    A referral is not an authorization or guarantee of payment. Contact the PRC office to see if the services will be covered by SCIHP.
    4The doctor sent me to the Emergency Room (ER), will the clinic going to pay the bill?
    Even if the doctor tells a patient to go to the ER it is not an authorization or guarantee of payment. The patient is still required to contact PRC within 72 hours (Elders 55+/Disabled patients have 30 days) and to have an alternate resource, such as Medi-Cal. If the patient does not have Medi-Cal, they must apply for it within the month of the ER visit.
    5I applied for Medi-Cal but was denied because my income or property exceeded the allowable amount.
    A Medi-Cal denial due to over income or over property, meets the requirement for PRC. The denial must be submitted to PRC and is valid for 1 year from the date of the denial.
    6I tried to see the doctor but couldn’t. I went to the ER, shouldn’t the clinic pay?
    Unfortunately, no, the clinic is always the payer of last resort. All patients must apply for or be currently active on Medi-Cal. The same answer applies if the patients goes to the ER because they are told the doctors are unable to see them. Patients still need to notify PRC of any Urgent Care/ER visits within 72 hours of the emergency visit (Elders 55+ have 30 days). Bills must be turned in within 180 days of the date of service.
    7Aren’t all outside services covered by SCIHP?
    Because funding is limited, the PRC program is designed to provide for the payment of a limited number of services, not available at the clinic, according to established levels of care. The board has approved payment of levels I-III.
    8I was seen at the clinic and had lab work done, now I have received a bill for the lab work. Because I was seen at the clinic, isn’t the lab work part of the visit and shouldn’t it be covered by the clinic?
    Because the lab at SCIHP is not a full-service lab, some lab work drawn in the clinic is sent to an outside laboratory, such as Quest or LabCorp. This is considered an outside service. All patients must have an alternate resource, such as private insurance or Medi-Cal.
    9I have Medi-Cal, but I have a share of cost. I am Native American from a California Tribe; do I have to pay my share of cost?
    No, California Native Americans (Federally recognized or in accordance with the Indian Health Care Improvement Act, P.L. 94-437) are eligible for coverage by PRC. If you are referred for outside services (within the levels of care I-III) and live within SCIHP’s service area, PRC covers your share of cost to the outside provider.
    10I am Native American, live in Sonoma County, and see a SCIHP doctor, but I am from a tribe that is out of state. Am I eligible for PRC?
    Our policy has changed in 2002, Native Americans who are from an out-of-state tribe are not eligible for PRC.
    11I am eligible for PRC and was referred to an outside provider with approval from the PRC, but I am receiving bills.
    If you are eligible for PRC to cover your outside services and are receiving bills, you must give them to the PRC for consideration of payment. Bills submitted MUST be itemized. It is the responsibility of the patient to obtain an itemized statement. SCIHP is unable to obtain this on your behalf due to HIPPA.
    12I have a bill that is from last year, can I still bring it in for payment?
    All bills must be submitted no longer than 180 days from the date of service. Please understand that the 180 days starts from the date you received the services, not from the date you received the billing statement. All bills that are over 180 days will remain the responsibility of the patient.
    13I have a bill from my hospital stay, will PRC cover the balance?
    At the present time, only outpatient services are covered. Inpatient hospital care is not a covered service. All patients are responsible for any amount not covered by their insurance for an inpatient visit. The same applies to patients who have Medi-Cal with a share of cost.
    14How do I submit my bill for payment?
  • Stop by the PRC office and drop off.
  • Mail to:
    Sonoma County Indian Health Project, Inc.
    Attention: Purchase Referred Care (PRC)
    144 Stony Point Road
    Santa Rosa, Ca 95401
  • Fax to PRC confidential: (707)544-2607