PURCHASED REFERRED CARE (Formerly CHS) MISSION STATEMENT
Purchased Referred Care-PRC mission is to provide appropriate access for Sault Tribe Members to achieve high quality care beyond what is available through Tribal Health facilities. PRC will work within financial resources and will clearly communicate its program and services to Tribal members.
WHAT IS PURCHASED REFERRED CARE?
Purchased Referred Care benefits are established by Federal law and regulations and funded through appropriations from the Federal Government. Tribes establish priorities of coverage based on funding appropriated as to what services they are able to provide to their members. Members should not rely solely on PRC for their medical coverage. If members are eligible for an alternate resource such as Medicare, Medicaid, MI Child/Healthy Kids, VA, employee sponsored insurance, etc. they should apply for those programs. PRC is the payor of last resort. PRC may be used as a secondary payor should there be a primary insurance on a “covered service” authorized by PRC to pay.
BEMIDJI AREA PURCHASED REFERRED CARE – MEDICAL & DENTAL PRIORITY GUIDELINES
Definition of Priorities with Examples
PRIORITY I: Pose or potentially pose a threat to Life, Limb, Senses (diagnosis and treatment of injuries or conditions that, if left untreated, could result in uncertain/potentially grave outcome).
Evaluation and treatment are essential to daily function. Delay in treatment is not medically justifiable.
PRIORITY II: Primary and Secondary care. Inpatient & Outpatient care services that involve the treatment of prevalent illnesses/conditions that have a significant impact on morbidity and mortality. Treatment may be delayed without progressive loss of function or risk to life, limb, senses, may require specialty consultation.
PRIORITY III: Services for the Restoration of Functionality (Care aimed at the amelioration of symptoms and disability).
PRIORITY IV: Chronic Care and Rehabilitation Services (Care that prevents long-term disability and rehabilitative services).
PRIORITY V: Excluded (cosmetic, experimental, or investigational), Alternative Care, Extended Long-Term Care, and Complex Rehabilitative Oral Health.
Acceptable alternatives exist. https://www.cms.gov/Center/Special-Topic/Medicare-Coverage-Center.html?redirect=/center/coverage.asp
GENERAL NOTES ON PRIORITY ASSIGNMENTS: Diagnostic assessments (laboratory, radiologic, or procedural modalities) align with the medical priority of the condition being
diagnosed or treated. Medical/Surgical consultations align with the medical priority of the condition being diagnosed or treated.
|
PRIORITY I (Examples) |
PRIORITY II (Examples) |
PRIORITY III (Examples) |
|
ALL MEDICAL EMERGENCIES (such as) · Eye (Acute threat to vision) · Dental (severe bleeding, airway compromise, fractures, abscess, need for oral surgery to prevent threat to life, severe early childhood caries) · Mental Health (Immediate danger to self or others – Acute inpatient) · Child Abuse/Neglect · Sexual Assault · Substance Use Disorder/Withdrawal (Medically managed/monitored inpatient) Diagnostic assessments: (e.g., laboratory, radiologic, or procedures) Treatment: may entail medications, hospitalization, surgery, or procedural interventions. Examples Include, but are not limited to: · Systemic or local infection, acute or chronic; · Unstable disease condition, including cardiac, vascular, pulmonary, GI, renal, endocrine, hematologic, urologic, gynecologic, neurologic, or psychiatric conditions; · Oncologic condition; · Fracture care; · Pregnancy, complications of pregnancy, delivery; · Non-deferrable potential surgical condition, such as appendicitis, acute cholecystitis, urologic stones or obstruction, or GI bleeding; · Diagnostic EGD or colonoscopy; mammogram, or further procedure as indicated; · Colposcopy |
Examples include, but are not limited to: · Health maintenance for children and adults; · Primary or secondary care of chronic illness, injury, or bodily dysfunction, including diagnostic assessments, and interventions to optimize health and function, and prevent complications; · Mental Health (outpatient); · Acute Outpatient Substance Use/Opioid Use Disorder; Medication Assisted Treatment; · Dental: Primary/secondary care of dental disease. Anterior root canal with good/fair prognosis, extraction of asymptomatic wisdom teeth with inadequate space; · Immunizations; · Elective surgeries necessary to improve function or alleviate pain; · Elective health screenings and procedures which are recognized as within national standards of care; may be deferrable; such as: o Screening mammogram o Screening colonoscopy o Tubal ligation o Vasectomy |
Acute Inpatient Rehabilitation Cardiac Rehabilitation Audiology (and hearing aids) Optometry (routine eye exams) Dental: Premolar root canal with good/fair prognosis Physical Therapy Occupational Therapy Durable Medical Equipment (Medicare/Medicaid Approved)
|
|
PRIORITY IV (Examples) |
|
PRIORITY V |
|
Skilled Nursing Facility Elective and/or restorative medical/surgical procedures that require medical justification for the purpose of enhanced quality of life, such as breast reconstruction/reduction, some plastic surgeries; or for which alternative options exist, such as obesity surgery; Organ transplantation (CMS approved); Optometry (contact lenses, visual training); Dental: Rehabilitative Oral Health Services. Molar root canal with good/fair prognosis; Mental Health/Substance Use Disorder (clinically managed residential) |
|
Extended Care/Nursing Home Cosmetic (non-restorative) procedures Experimental or investigational treatments or procedures (per CMS standards) Alternative or complementary treatments (acupuncture, chiropractic, naturopathy, homeopathy) Dental (Complex Rehabilitative Oral Health Services such as poor prognosis endodontics or periodontal surgery) |
WHO IS ELIGIBLE?
Sault Tribe members residing within the (Purchased Referred Care Delivery Area) as established by the Federal Government. Non Indian dependents covered for pre and post natal care and delivery, for communicable disease. Tribal members must apply for PRC and be a permanent resident of the PRC Delivery Area. PRC service area consists of seven counties: Mackinac, Chippewa, Luce, Schoolcraft, Delta, Alger, and Marquette.
Purchased Referred Care Eligibility Requirements
Sault Tribe members residing within the Purchased Referred Care Delivery Area must have a completed application on file and approved for PRC prior to PRC paying for a service deemed covered outside of our Tribal Clinics. The applicant must provide proof of income, such as current 1040 tax return, and proof of residency. Proof of residency would include copies of driver's license, utility receipts, voter registration, etc. Applicant must be enrolled in PRC 90 days prior to PRC assisting with an Inpatient Stay. Proof of income is used to determine eligibility for alternate resources. If members are eligible for an alternate resource, such as Medicaid, Medicare, health insurance provided by employer, VA, etc. they need to apply for those programs. PRC is the payor of last resort. PRC may be used as a secondary payor for any copays or deductibles on a "covered" service authorized to pay by PRC.
*Sault Tribe Eligible PRC Member's Responsibility
It is the member (patient) responsibility to request assistance (prior authorization/voucher) by contacting PRC office directly 906-632-5220 for all services not provided at our Tribal clinics in which they are requesting assistance. PRC staff will determine member’s eligibility for the program at this time and let the member know if it is a covered service. The request for assistance should be done prior to the service being provided unless it is an emergency visit which has to be reported within 72 hours to PRC. Emergency room report notes will be reviewed to determine priority unless sent there from the nurse triage line in each area (see contact numbers listed here).
After Hours/Week-end Coverage
If you feel the need to be seen after hours/week-ends when Tribal clinics are closed you must call the nurse triage line in your area where your primary care provider is located for it to be considered by PRC. The triage nurse will provide medical advice. You may be referred to nearest walk-in, urgent care, emergency room, or make appointment with your primary provider at tribal clinic. If you are referred from the nurse triage line to nearest urgent walk-in or emergency room, your bill will more likely be covered by PRC if you are eligible for PRC. Please call PRC for your voucher within 72 hours and to make sure you are on program.
Tribal Health Center phone numbers to access after-hours nurse triage:
Sault Tribal Health Center 906-632-5200
St. Ignace Health Center 906-643-8689
Manistique Health Center 906-341-8469
Munising Health Center 906-387-4721
*It is the member’s responsibility to call PRC-Purchased Referral Care for their voucher for all out of clinic services, not the referral coordinators at each clinic site. They set up your referral appointments to the outside providers that your clinic provider is referring you to. PRC Staff determine if the referred care is a covered service based on funding and established priorities of coverage for that fiscal year. Referrals are marked by Categories, Priority 1A, 1B, 2, 3, 4, 5 by the clinic providers based on guidelines set up by Indian Health Service. There may be extenuating circumstances where the provider requests Special Committee Review. The committee consists of Medical Director, Clinic Manager, Health Director, Nurse Supervisor, PRC Manager who meet when there is a need.
For FY 2023 all Referrals categories 1A, 1B, Cat 2, Cat 3, Cat 4-Joint Replacement surgeries Covered. Emergency Room & Walk-In visits will be reviewed for nurse triage call when Tribal Clinics are closed. Non-formulary medications from ST providers are covered, exception over the counter medications non-covered. Scheduled Medications will be Reviewed. High-cost prescriptions will be reviewed for coverage and for Special Order in-house
340b pricing. Other Medical supply requests will be reviewed for coverage by PRC staff and or Special Review Committee. Sleep studies are covered. CPAP covered for moderate to severe sleep apnea, or with family hx of cardiac disease. Physical Therapy (PT) covered at Big Bear-Sault area and PT in out-lying areas covered to contracted Providers with Referral from Tribal Provider.
*Added Service Sept 2019 – Incontinence Supplies purchased at 340B Pricing
And Distributed through our Community Health Staff at each Tribal Clinic Site
offering pads, panty liners, briefs, protective underwear, under pads, disposable washcloths and Thera body shield
*Added Services in May-2018
Glasses-when received at Tribal Clinics-PRC eligible members only. Eligible for one pair up to maximum benefit of $200. Eligibility date every 2 years based on purchase date of last pair from tribal optical. PRC is payor of last resort. Members must bill their health insurance if they have coverage for glasses and submit bill and explanation of benefit from their ins. to PRC for reimbursement. PRC will only reimburse the difference in the out-of-pocket expense not covered by the ins. up to the max benefit. Example cost $240, Ins Paid $150, PRC reimbursement $50.
Please contact tribal optical dept in your area to schedule your exam.
Sault Ste. Marie 877-256-0009
St. Ignace 877-256-0135
Manistique 866-401-0043
Bariatric Surgery covered in Sault area once all Protocol Steps have been followed and completed at STHC, a Referral from primary care provider to Advanced Surgical Care-Dr. Adair. Discuss Protocol with your Tribal Provider, Nutritionist or Health Educator at Sault Tribal Health Clinic 877-256-0009.
Purchased Referred Care office is located on the 3rd floor of Sault Tribe Health & Human Services Bldg., 2864 Ashmun St., Sault Ste. Marie, MI 49783.
1-800-922-0582, 906-632-5220 fax 906-632-5248.
Our Mailing address is: PO Box 1628, Sault Ste. Marie, MI 49783.
Tina Fox PRC Utilization Manager ext. 43350
Carol Pages-Montie PRC Certifier ext. 43372
Kim Menard Patient Care Coordinator (A-C) ext. 43380
Niki McKechnie Patient Care Coordinator (D-H) ext. 43385
Kelly Menominee Patient Care Coordinator (I-Mc) ext. 43381
Vicki Puidokas Patient Care Coordinator (Me-R) ext. 43384
Claudette Crook Patient Care Coordinator (S-Z) ext. 43382
Click here to download the PRC Application
