Purchased Referred Care

What is Purchased / Referred Care?

Purchased / Referred Care (PRC), formerly called Contract Health Services, assists Santo Domingo tribal members to pay for specialty medical, dental and mental health care services that are not available at the Santo Domingo Health Center, and for emergency care.

All Purchased / Referred Care must be approved in advance.

The Purchased/Referred Care is NOT AN ENTITLEMENT program nor is it an insurance program. The Santo Domingo Health Center PRC department cannot guarantee that funds will always be available.

PRC funds are intended to help pay for care when no other sources of health care payments are available or to supplement other alternate resources after they have been exhausted. The PRC program is PAYOR OF LAST RESORT, no one else or any other department can authorize payments. PRC payments are authorized through a process using federal guidelines and eligibility criteria.

Eligibility for PRC Services

The PRC program operates under federal guildelines. In order to be eligible, you must provide record of:

1. Tribal membership: You must show proof of membership in the Santo Domingo tribe.


2. Residency: Tribal members must reside in Sandoval or Santa Fe Counties.
   
3. If you live off the reservation, you must have a certified letter from the Tribe showing your close social and economic ties to the reservation.
4. If you are a full-time student you must have the PRC Student Form completed by your school.


5. Approval: Prior approval is required for all PRC funded care.


6. Obtain prior approval from the PRC Department for any non-emergency services.


7. Notify the PRC Department (505-465-3075) within 72 hours of receiving emergency services. Elderly or disabled patients have 30 days to notify the PRC Department.

PRC Requirements

Santo Domingo members who have other forms of insurance such as Medicare, Medicaid etc., please be advised other forms of insurance will be billed first. Any remaining charges for an approved service will be paid for by the PRC Program. Please present your insurance information at every visit here at the Santo Domingo Health Center (SDHC) and at all referred care appointments.

PRC ID CARDS

The PRC ID Cards are new to our department and are now available to eligible Santo Domingo Pueblo tribal members that qualify for the program.

USE THIS CARD: When an individual presents to an Emergency Room, Urgent Care facility or any specialist visit they need to present this card at time of service along with other form (s) of insurance such as Medicare, Medicaid or Private Insurance.
Reminder that PRC is ?Payor of Last Resort?.

THE PURPOSE OF THE ID CARD:
This card will let the outside entities know that you are a Santo Domingo member and they should send us the appropriate information on your behalf. This helps the PRC department determine your eligibility status and an approval for PRC payment.
This will avoid these entities from sending your information to the wrong PRC department or IHS facility.
Another benefit is this card can assist in our PRC department receiving a timely notification of an Emergency Room or Urgent Care visit. Ultimately all individuals are responsible for giving notification to SDHC PRC Department.

Please remember to always present your insurance cards at every doctor visit!!

Denials and Appeals

If you should receive a ?Denial? from our PRC department, you have the right to appeal for reconsideration. These are the steps:

• You the patient will receive a certified denial letter in the mail from the Santo Domingo Health Center PRC Department.
• Upon receipt of the letter, you have 30 days from the date you receive the letter to write and submit your appeal. (Instructions will be on the letter)
• When you receive the appeal letter, we will review and discuss your case among the PRC Resource Management Committee and a decision will be made in that forum.
• When a decision is made, the individual will be notified immediately of the result.
  

Questions & Answers

Q. Why are Santo Domingo Pueblo descendants not eligible for PRC off the reservation?
Santo Domingo Pueblo descendants residing off the reservation may be eligible if they meet certain conditions. Pursuant to 42 C.F.R. 136.23 (a)(2)(i) and (ii), if not residing on the reservation such individuals must live within the CHSDA and (1) be members of the tribe(s) located on the associated reservation or (2) "maintain close economic and social ties with that tribe or tribes."

Q. An SDHC or IHS doctor referred me to a specialist. Why am I being held responsible for the bill?
Referrals are not a guarantee of payment. A referral is a recommendation for treatment or tests only. The PRC program must review the referral to make the determination for PRC approval of payment. PRC eligibility requirements must also be met.

Q. If we are guaranteed health care from our treaties as long as the water flows and the grass grows, why are Indians required to apply for AR?
It is required under 42 CFR 136.61, Payor of last resort. While some treaties mention health care, the Indian Health Service is not an entitlement program, and therefore funding for PRC is not guaranteed by the Federal government. AR allow PRC funds to be conserved, thereby providing health care for more Indian beneficiaries.

Q. If I am residing in an area where there is a federally recognized tribe, but no reservation, can Social, Economic Ties be automatic to that tribe or do I have to apply/petition?
No. Social and economic ties are not automatic. The individual has to apply to the Tribe.

Q. If a student is covered under PRC, are the student?s dependents also covered?
Yes, dependents may be covered for PRC up to 180 days if they were eligible for PRC at their original (home) CHSDA.

Q. If I move from one federally recognized reservation to another federally recognized reservation, does the 180-day rule apply?
The 180-day rule applies until the client establishes residency and becomes eligible in another CHSDA.

Q. Can Non-Indians be eligible for PRC?
Yes, but only for three classes of non-Indians. These include (1) non-Indian women pregnant with an eligible Indian's child during pregnancy through postpartum (2) non-Indians under 19 who are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian and (3) non-Indian spouses of eligible Indians if all such spouses are made eligible through a tribal resolution.

Q. What does Social, Economic Ties mean?
Close social and economic ties are determined by the governing body, or designee, of the local Tribe. A letter from the Santo Domingo Tribal office must be in place and submitted on behalf of the tribal member for PRC services.