Medical/dental care provided at an IHS or tribal health care facility is called Direct Care.
The Purchased and Referred Care Program (PRC) 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.
The following requirements apply to each referral/request for IHS to pay for medical care for any AI/AN who receives care away from an IHS or tribal health care facility.
Eligibility
Purchased and Referred Care or PRC (formerly known as Contract Health) Services are available for Native Americans or those deemed eligible for membership in a federally recognized Native American Tribe AND who reside within the Cherokee Nation 14-county reservation (PRC/CHS delivery area). Proof of residency may be required.
Eligibility Exceptions:
Purchased and Referred Care Delivery Area
The PRC service delivery is determined by the address of permanent residence. The service delivery areas are divided among native tribes and the Indian Health Service, as well as the type of health service requested; inpatient, emergency room, or outpatient. The service delivery areas can vary within short distances. Referred care coordinators will identify the service delivery area, and can explain which PRC/CHS office is responsible for inpatient, emergency room, and outpatient services. It is possible to receive services from two different PRC/CHS systems; one for inpatient care and one for outpatient services. Emergency room services vary as well.
Referrals
A PCR referral is generated when a CNHS or IHS Medical Provider determines a patient has a medical need that cannot be managed within Cherokee Nation Health Services or the Indian Health Service. Once the referral is approved, it is used for ONE visit (or date of service) only. For changes in appointment dates, any additional appointments, testing, or other services, a NEW referral must be generated by a Cherokee Nation or IHS provider. Each referral is valid for one date of service. Once a referral has been completed by the medical provider it will be processed by the PRC/CHS office and assigned to a Referred Care Coordinator (RCC). At this time, the patient may be asked to meet with the RCC depending on their Health Center's procedure. The RCC will confirm the patient's eligibility for PRC/CHS, and identify their assigned PRC/CHS delivery area.
The priority of referrals is based on several factors such as:
If the patient does not reside within the purchased referred care delivery area in which the referral is being processed, the RCC will forward the referral and indicated medical information to the appropriate purchased referred care delivery area. Patient are required to have an active chart with the facility in their PRC/CHS Delivery Area, so they may be required to travel to that office to create or update a chart.
Patients will be notified if their referral has been sent to another PRC/CHS office. Funding is a variable that may affect approval. Diminished funds can narrow the approval range to the most severe or life-threatening conditions. A patient's referral funding will come from the purchased referred care delivery area to which they are assigned.
Once a patient's referral has been approved or denied, a notification is sent electronically to their medical provider and the patient will be notified by mail. The RCC will begin the scheduling process immediately upon notification of an approved referral. Some health facilities that patients are referred to will call the patients directly for an appointment. If this happens, patients should contact their PRC/CHS office to verify the approval of their referral and inform them of the appointment date.
When a referral is approved, all information will be mailed to the patient along with the referral, which they must present to the facility where they are being referred. The referral has important medical information for the specialist to determine the best course of action for the patient's care, as well as information needed for PRC/CHS to pay for their services.
Patient Should Bring the Following to Their Appointments:
Applying for Third Party Coverage is Required
If patients do not have health insurance, they are required to apply and file for any assistance available to them. This can be initiated at any CNHS health center by visiting a Patient Benefit Coordinator, the county DHS office, funding agency, or if the patient is hospitalized at another facility. PRC is a payer of last resort, which means patients must apply for all available resources before PRC can consider payment. If the patient fails to complete the necessary steps needed to complete the application processes (e.g., verify income, household size, complete paperwork, etc.), they may be responsible for any charges accrued.
Denied Referrals
Patients will be notified by mail of any denial. Included with the denial will be instructions for filing an appeal. The patient's primary care physician is the best resource to help complete the appeal form. The best approach to an appeal is to provide more detailed medical information and history concerning the patient's medical need. Three appeals are permitted for each denied referral. Patients and providers should pay close attention to the date and deadline for appeal submissions.
Guidance for patients who require emergency care at a non-tribal health care facility:
If a patient needs emergency health care, they should always report to the nearest emergency department or call 911. Sometimes, this means that care will be provided by a non-tribal healthcare facility that is not operated by Cherokee Nation Health Services (CNHS) or Indian Health Services (IHS).
To ensure that patients receive proper coverage in this scenario, the following steps should be taken.
Step 1: Patients must notify CNHS Contract Health (Purchased/Referred Care) within 72 hours. If the patient is seen in an emergency room or admitted to a hospital that is not tribally operated, they must inform their CNHS Contract Health (Purchased/Referred Care) office within 72 hours of the emergency visit. The patient may call, and a family member or friend may call on their behalf.
Step 2: Patients must complete the appeal packet provided by CNHS. After notifying CNHS Contract Health (Purchased/Referred Care), the patient will receive an appeal packet along with a request for information by mail. If the patient needs clarification on how to complete the packet, they may contact their local CNHS Contract Health (Purchased/Referred Care) office. Patients must also have a chart created within Cherokee Nation Health Services database.
Cherokee Nation offices cannot accept notifications for patients who reside in Claremore Indian Hospital, Creek Nation, Northeastern Tribal Health, or Pawnee Service Unit funding. Patients will be directed to contact those service units if they reside in one of those areas.
Notification Numbers for Emergency Care at a Non-Tribal Health Care Facility.
Any billing patients receive, for which they have obtained an approved referral may be sent to their local PRC office.
Frequently Asked Questions regarding the policy change within the CNHS impacting how exclusive UKB members access Purchase and Referred Care (PRC).
