PRC

Medical/dental care provided at an IHS or tribal health care facility is called Direct Care. The PRC Program is for medical/dental care provided away from an IHS or tribal health care facility. PRC is not an entitlement program and an IHS referral does not imply the care will be paid. If IHS is requested to pay, then a patient must meet the residency requirements, notification requirements, medical priority, and use of alternate resources.

Purchased/Referred Care (PRC) is not an entitlement program – meaning it is not an automatic guarantee of payment.  PRC is a set of benefits for a group of patients who meet specific guidelines.  Applying for Alternate Resources (AR) is one of the requirements for PRC eligibility (42 CFR 136.61, Payor of last resort). Approval of PRC payment is considered only after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to make a good faith application for the alternate resource before any PRC funding will be considered.  Travel and gas voucher assistance is part of PRC funding.  Additionally, Indian Health Service (IHS)/Tribal facilities are considered as a resource for care to be used before seeking outside services.  This means if you can receive the service at K’ima:w, that service should be used first.

Medical or Dental Referrals are not a guarantee for PRC payment. Although your provider may recommend additional care outside of our facility, it may not meet all the guidelines for PRC funding.  This is considered a Medical or Dental referral.  It only becomes a PRC referral once it meets the guidelines for PRC funding.  Your provider’s referral request will be routed and reviewed to see if it meets PRC requirements.  All PRC eligibility requirements must be met for guarantee of payment can occur. A patient must meet residency, notification, medical priority, Tribal identity and use of alternate resources (42 CFR 136.23, 136.24 and 136.61) in order to be eligible for PRC.  Be aware PRC guidelines may be different for each IHS funded clinic, so what applies at K’ima:w Medical Center (KMC) may not apply at another local IHS clinics.

In those cases where the referral does not meet PRC criteria, the patient will liable for any service or supply provided outside of our compound.  An example of a non-covered PRC referral would be for dental implants or implant buildups.  PRC currently does not the funding to cover dental implants, and those referred services  would be the responsibility of the patient.

Each visit to a non-Indian Health Service (IHS) health care provider and those associated bills are distinct and must be examined individually to determine PRC eligibility.  All PRC requirements must be met for each episode (treatment) of care.

Example: If a PRC authorization is issued for a specific treatment, K’ima:w Medical Center (KMC) - PRC will pay the first medical treatment.  Follow-up care or additional medical care is to be done at the nearest accessible IHS or tribal facility; or will require approval with a new PRC authorization. If this process is not followed, the patient may be responsible for the expense.  If you are not sure if your outside services will be covered by PRC, you should contact your PRC Department before receiving outside services.