Purchased/Referred Care (PRC) 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) 521-4634 or (707) 521-4539 for any questions. PRC Frequently Asked Questions 1 What is Purchased/Referred Care? 2 I am Native American, why do I need to get Medi-Cal or other insurance? 3 The doctor gave me a referral, doesn’t that mean the clinic will pay? 4 The doctor sent me to the Emergency Room (ER), will the clinic going to pay the bill? 5 I applied for Medi-Cal but was denied because my income or property exceeded the allowable amount. 6 I tried to see the doctor but couldn’t. I went to the ER, shouldn’t the clinic pay? 7 Aren’t all outside services covered by SCIHP? 8 I 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? 9 I 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? 10 I 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? 11 I am eligible for PRC and was referred to an outside provider with approval from the PRC, but I am receiving bills. 12 I have a bill that is from last year, can I still bring it in for payment? 13 I have a bill from my hospital stay, will PRC cover the balance? 14 How do I submit my bill for payment? SCIHP - Santa Rosa: Main Clinic 144 Stony Point Road Santa Rosa, CA 95401 Main Number: 707-521-4545 Hours of Operation SCIHP - Manchester/Point Arena: Satellite Clinic 10A Mamie Laiwa Rd. Point Arena, CA 95468 Main number: 707-882-2877 After Hours: In case of an emergency: call 911 Urgent Medical Need: (707)521-4500 Urgent Behavioral Health (707)521-4550 Like us on Facebook © 2021 Sonoma County Indian Health Project All Rights Reserved. designed by