Picuris Medical Center

Purchased Referred Care

What is Purchased Referred Care (PRC)?

PRC is an Indian Health Service (IHS) program that pays for medical care provided outside an IHS or tribal facility when that care cannot be delivered internally. PRC is provided through Picuris Medical Center (PMC) for patients meeting the five eligibility requirements mandated by regulation:

  1. IHS eligibility – Patient must be an eligible American Indian or Alaska Native.
  2. Residence in PRC Delivery Area (PRCDA) – Must live within the tribe’s designated geographic service area.
  3. Notification / Authorization – PRC must approve the referral before care (or emergency reported within required timeframe — usually 72 hours).
  4. Medical necessity – Service must be medically necessary and not available at an IHS or tribal facility.
  5. Alternate resources used first – Patient must apply for and use other coverage (Medicaid, Medicare, VA, private insurance) before PRC pays.

Each person needing and applying for PRC Assistance must have a medical chart at PMC to begin the eligibility process.

History of PRC

PRC was formerly called Contract Health Services (CHS) which was signed into law on September 30, 1976 (PL94-437) and permanently authorized in by the Indian Health Care Improvement Act (IHCIA) on March 23, 2010.

Use of PRC Funds

PRC funding is considered the “payor of last resort” meaning that it requires all other payment options, including private insurance (for example Employer Provided Insurance), publicly funded health insurance (Medicaid) or age eligible insurance (Medicare) coverage to be billed first. PRC is NOT health insurance coverage and not guaranteed to cover all your medical costs. PRC is financial assistance for a patient to receive health care with outside providers or specialist. The Federal government has an obligation to provide healthcare to the native populations across North America based on treaty responsibilities; however, PRC is only funded annually through congressional appropriations.

Patient Responsibility

For Emergency Services

Eligible patients with a medical emergency may seek immediate care and must notify PRC Staff within 72 hours of the beginning of treatment or admission to a health care facility. Elderly (65+) and/or disabled patients have 30 days to notify Picuris Medical Center PRC of emergency medical care received from a Non-I.H.S medical provider or at non-IHS medical facilities.

Non-Emergency Referral Services (Outpatient specialty services)

For clinically indicated, non-emergency conditions that are not available as direct care services at Picuris Medical Center or an IHS clinic/Hospital, a referral is initiated by the clinical provider following a patient evaluation. A determination of medical necessity based on the medical priorities is one of five PRC Eligibility requirements which must be met before approval for PRC payment for the referred service(s).

For more information please contact the Picuris Medical Center PRC program staff at 575-251-8010