WHY DO I NEED HEALTH INSURANCE COVERAGE IF I GET SERVICES FROM Peter Christensen Health Center PURCHASED/REFERRED CARE (pchc PRC)?
Services provided at Peter Christensen Health Center (PCHC), an Indian Health Service (IHS) facility, are direct care services available to you. The Purchased Referred Care (PRC) program is for speciality services not available at PCHC.
Outside services require a PRC referral approved by your PCHC primary provider, this does not imply the care will be paid for.
The PRC program at PCHC follows IHS federal regulations which state you must meet certain eligibility requirements, a few examples are listed here:
- Enrolled in a Federally recognized Tribe or a first Descendant of a Federally recognized tribe.
- Residency requirements
- Notification requirements
- Medical priority
- Application/screening of alternate resources
PRC is considered a payer of last resort and does not function as an insurance company.
When you receive services from PRC, your insurance will be billed first, PRC will then process the balance after insurance. This benefits the tribal community allowing PRC to provide more services to others.
The Benefit Specialist at PCHC is available to assist you in applying for alternate resources. If you would like more information about alternate resources or you have questions please contact the Benefit Specialist at PCHC.
WHEN WILL YOUR HEALTH CARE NOT BE COVERED BY PRC?
- When you obtain services outside PCHC that are offered at PCHC without approval
- When you fail to apply for other healthcare funding resources for which you may qualify or provide documentation that verifies you are not eligible for such funding
- If you seek care from an E.R. or Urgent Care facility and you, a person acting on your behalf or a provider, do not contact PCHC within 72 hours (30 days for elders & disabled)
- If the Managed Care team deems the visit not medically necessary or that the reason for the visit could have waited to be scheduled at PCHC
- If the visit is during the hours that PCHC is open (8 am – 4:30 pm), there must be phone call documentation stating PCHC is directing you to go an outside facility.
- If you are offered a same day appointment and deny the available appointment at PCHC, the visit may be denied by PRC
- If an E.R. / Urgent care provider tells you at the end of your visit that you must schedule with your PCHC Primary Care provider for Continuance of Care, and do not, your visit may be denied
- If you leave your E.R. / Urgent Care visit Against Medical Advice (AMA), your visit will be denied
- Requests for referrals for appointments that have been attended to already will be denied, to avoid this, please inform the PCHC PRC Referral Coordinators of your appointment dates as soon as possible
Services from PCHC PRC may denied if you have not complied with the guidelines of the program.
You can obtain booklets at the PCHC front desk, “Understanding Peter Christensen Health Center’s Purchased Referred Care Services Program”, for further explanation of these and other eligibilities.