1. Purchased/Referred Care Pokagon health services

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. PRC is PAYOR OF LAST RESORT
Alternate Resources
PRC is PAYOR OF LAST RESORT
Under 42 CFR
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

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

12. 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:

13. 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

14. 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

15. Questions ?