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Community Health Education Newsletter August 2018

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ATTENTION:

As of July 1, 2017, the Sault Tribe will no longer assist in paying for walk-in/emergency room services to an outside entity when our Tribal Health Clinics are open, unless you have been referred from the clinic.  If you are seeking treatment when our clinics are closed, you MUST call the After Hour Telephone Nurse for medical advice before seeking care elsewhere for possible payment by the Tribe. 

To access the After Hours Telephone Nurse, call the Tribal Clinic that you receive your primary care at:

  • 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

If you are sent to an outside entity for care, you must call Purchased Referred Care (formally known as Contract Health) at 906-632-5220 or 1-800-922-0582 within 72 hours for your urgent/emergent voucher request.


 

CONTRACT HEALTH SERVICE HAS NEW NAME-PURCHASED REFERRED CARE

Indian Health Service has changed Contract Health Service Name to Purchased Referred Care (PRC) to most reflect what services are provided. This change was made recently at the federal level and tribes have been notified of this change within the last few months.

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. 

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 72hours 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 program. 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.

 

Presently For FY 2018 all referrals categories 1A, 1B, Cat 2 and Cat 3, Joint Replacement surgeries are covered by PRC without review. Emergency Room & Walk-In visits will be reviewed for nurse triage call when Tribal Clinics are closed. All non-formulary medications from ST providers are covered. Other Medical supply requests will be reviewed for coverage by PRC staff and or Special Review Committee. Scheduled medications are reviewed.  Sleep studies are covered.   CPAP covered for moderate to severe sleep apnea.  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 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 only in Sault area once all Protocol Steps have been followed and completed, with 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.

 

Purchase Referred Care

1-800-922-0582, 906-632-5220

Fax 906-632-5248.

 

PRC office is located on the 3rd floor of Sault Tribe Health & Human Services Bldg., 2864 Ashmun St., Sault Ste. Marie, MI 49783.

 

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-F)    ext.  43380

Nicole McKechnie       Patient Care Coordinator (G-L)    ext.  43381

Danielle Walcher        Patient Care Coordinator (M-Q)    ext. 43384

Claudette Crook         Patient Care Coordinator (R-Z)     ext.  43382

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