Purchased & Referred Care (PRC)
The Purchased & Referred Care (PRC) program is designed to assist eligible American Indian patients in accessing essential healthcare services that are not available at Choctaw Health Center. Through this program, we ensure that our patients receive the specialized care they need to support their health and well-being.
FAQs
When should you contact PRC for an Emergency Notification?
- You must call Purchased & Referred Care within 72 hour notification of any health care services that you received after Choctaw Health Center hours. If you cannot notify us, someone on your behalf must contact us with your full name, date of birth, reason for emergency, date of service or admission, name of emergency room facility and a working telephone number.
- During non-working business hours, (after 4:30 pm, weekends, and holidays), please leave a message on the PRC Program voicemail.
- The patient is required to get a copy of the ER record for that visit and bring it to the PRC Program. It will then be presented to the PRC Committee.
- The notification for the elderly (age 57+) and disabled is 30 days.
Payment will not be provided by PRC if the call is not made. Also, the Purchased & Referred Care Committee will review on a case-by-case basis and determine if approval of payment.
Do you need your own health insurance?
Yes. Purchased & Referred Care is considered the "Payor of last resort". It is mandated by law from the Indian Health Service. You must apply for an alternate resource of insurance such as but not limited to: Medicare, State Medicaid, and/or Private Insurance. Full-time employees with MBCI, PRR, or other Tribal Entities are eligible for health insurance at no cost to them.
What to do when you have an appointment with an outside provider?
Please notify your case manager one week before your scheduled appointment to request a referral for outside providers and specialists.
What if I missed my appointment?
Please keep in mind that Purchased & Referred Care will not pay for missed or no-show appointments.
What items do I need to provide?
Submit any determination letters or documentation that you receive from applying for State Medicaid, Medicare, and other private insurance. Purchased & Referred Care will not pay for any services that you receive if you do not follow through with applying or completing the application process for alternate resource.
What documents should I provide to the PRC Program?
Bring all bills and/or EOB's to the PRC Program. Please make sure to check to see if your alternate resource has paid the service. Otherwise, Purchased & Referred Care will not be eligible to provide payment.
What if my insurance sends me a questionnaire?
If your insurance sends you a questionnaire to do, please complete it. If you do not, your insurance may not cover your visit or services. This indicates that Purchased & Referred Care will not provide payment participation either.
How Purchased & Referred Care (PRC) Determines Payments
PRC makes their decision to approve or deny payment based on Medical Priority, Eligibility and Availability of Funds.
At the Purchased & Referred Care (PRC) program, payment decisions are made based on the following criteria:
Medical Priority: We assess the urgency and necessity of the requested healthcare services to ensure that critical needs are addressed promptly.
Eligibility: We verify that patients meet the established eligibility requirements for the program.
Availability of Funds: We evaluate the funding resources available to cover the requested services to ensure financial viability.
These criteria work together to help us provide timely and appropriate care for our patients.
Patient
Referral
A Choctaw Health Center provider is the person authorized to issue a Choctaw Health Center patient referral.
A referral is considered authorized if:
- The patient was seen and treated on-site at Choctaw Health Center and
- A Choctaw Health Center provider made out the referral
A referral is considered not authorized if:
- The patient referred themselves to a specialist for, or
- A private provider referred the patient to another private provider.
- The patient is making a personal request for a referral either over the phone or after receiving services from a private provider.
A referral is a request for health care services, NOT a guarantee of payment by Purchased & Referred Care.
Case Managers
Referrals pre-screened for eligibility and appointment scheduled.
Check Eligibility
Approved
Denied
Referral Issued to Patient
Denial Letter Issued to Patient
FI Issued Payment
Appeal Process
For further inquiries about the payment determination process, please feel free to contact us (601) 389-4060.