Purchased/Referred Care Pokagon health services

Purchased/Referred Care A federally funded program operated by Pokagon Health Services that purchases health care for eligible Tribal Citizens when services are not available directly

PRC Program Funding Funding for the PRC program comes from the Federal Government through Indian Health Services (IHS) IHS , an agency of DHHS, is responsible for meeting the treaty obligations to provide health care to American Indians and Alaskan Natives.  This provision grew out of the special government-to-government relationship between the Federal Government and Indian tribes established in 1787, based on Article 1, section 8 of the constitution. Courage, Family, Honesty, Humility, Love, Respect, Wisdom

PRC Program Operation Tribes are given the authority to operate their own PRC programs with the funding granted through IHS Program rules may differ from Tribe to Tribe, but most follow IHS guidelines For more information on the program as a whole, visit http://IHS.gov/PRC

Pokagon PRC - What’s Covered? DIRECT CLINIC SERVICES PRC COVERED SERVICES Primary Care – acute and well visits, immunizations, bloodwork, podiatry, dietician Specialist Care, ER/Urgent Care visits, Prenatal Care, Diagnostic Radiology, Screening Mammograms & Colonoscopies Dental Care – routine visits, cleanings, fillings, dentures Comprehensive Oral Surgery & Periodontal Care Behavioral Health – individual and family therapy, well-briety, smoking cessation Psychiatric Services, substance abuse treatment services Pharmacy Specialty Medication Prescription Lenses Routine Eye Exams

Pokagon PRC – Paying a Claim There are four parts to authorizing payment for a service not available under direct care at Pokagon Health Services: Eligibility Referral Authorization Alternate Resource Priority 1 – ER visits referred by PHS/Emergency Surgeries  Priority 2 – Specialty referrals/Elective Surgery/OB/Pediatric/Diabetic Eye Exams/Urgent Care Priority 3 – Preventative Screenings (Mammograms)/Pain Management/Routine Eye Exams Priority 4 – Chiropractic Care/Visual Training/Rehabilitation/DME

Eligibility A Pokagon Band citizen; or adopted, step or foster child of Pokagon citizen (up to 18); or pregnant woman with eligible Pokagon citizen’s child Is resident within the 10-county service area: Berrien, Cass, Van Buren, Allegan in MI. La Porte, Starke, St Joseph, Marshall, Elkhart, Kosciusko in IN Has established care with Pokagon Health Services either in Clinic, Dental or Behavioral Health, exceptions for pediatrics and pregnancy care Has completed an application for Alternate Resources, including Medicare, Medicaid, VA or Commercial Federal Requirements Berrien, Cass, Van Buren and Allegan in MI, La Porte, St Joseph, Elkhart, Starke, Marshall and Kosciusko in IN

Referrals All services require a Referral or Order from a PHS Provider PHS Referral must be made prior to services being rendered Referrals to specialists include any referrals made by the specialist if documented Self-referred services i.e. ER/Urgent Care visits must be reported within 72 hours

Authorizations Authorization numbers are generated prior to service based on Medical Priority Some services require review to determine Necessity, Priority and Availability of funds One Threat to Life and Limb – Emergency Care Two Primary and Secondary Care Three Preventative and Routine Care Four Long Term or Rehabilitative Care

PRC is PAYOR OF LAST RESORT Alternate Resources PRC is PAYOR OF LAST RESORT Under 42 CFR 136.61 All alternate resources including Commercial Insurance, Medicare, Medicaid and the VA must be billed prior to PRC The PRC program can assist to determine alternate resource eligibility prior to authorization of services

Eligibility & Authorizations To check if a patient is eligible for the PRC program call: 269-462-4401 Authorization numbers are added to Referrals or can be given over the phone REFERRAL ≠ ELIGIBILE

Claim Submission Submit claims on standard claim form to: Include all EOBs from primary payors Do not attach Medical Documentation Follow up after 30 days Pokagon Health Services Attn: Claims PO Box 180 Dowagiac, MI 49047 Fax: 269-782-3882

Denials, Resubmissions & Appeals Provider Denial: D01: THE PATIENT HAS AN ALTERNATE RESOURCE; PRC IS PAYOR OF LAST RESORT. PLEASE RESUBMIT THE CLAIM WITH THE PRIMARY EXPLANATION OF BENEFITS ATTACHED. Patient Denial: 037: THE EXPENSE WAS INCURRED WHEN ELIGIBILITY FOR THE PURCHASED REFERRED CARE PROGRAM WAS EITHER NOT ESTABLISHED OR HAD BEEN TERMINATED. Claim is missing information Resubmit correct claim for payment Patient is NOT responsible Patient not eligible or authorized Patient has 30 days to appeal Patient IS responsible

E-Claims in 2019 PRC will accept Professional and Institutional claims in electronic format through Change Healthcare early 2019 All PRC eligible patients will be issued a new PRC Card with a new 9-digit PRC Number A letter will be sent to providers with the electronic payor ID Electronic RA will not be available at this time Providers can opt to receive electronic fund transfer payments

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