Purchased Referred Care

Purchased Referred Care service is a financial resource meant to assist in payment for healthcare services received by tribal citizens not available at a tribal health facility like the Oyate Health Center.

One of the most confusing parts of receiving care at a federally funded Indian Health clinic or hospital is navigating the Purchased Referred Care process.

Funding for purchased referred care is decided upon by Congress. The lump-sum allocated is then divided nationally amongst Indian Health Service and tribally contracted health facilities. The level of funding each facility receives is based on the number of patients who had received care there in the last three years.

Ironically, the amount needed to cover healthcare costs in Indian Country is not met by Congress. Congress funds the Purchased Referred Care (PRC)program at about 60% of what is required. While the Oyate Health Center’s goal is to work towards finding alternative revenue sources, so that it can be less reliant on these dollars, the failure of the federal government to fully fund this program has resulted in the enforcement of strict federal guidelines on its use.

“Because IHS programs are not fully funded, the PRC program must rely on specific regulations relating to eligibility, notification, residency, and a medical priority rating system. The IHS is designated as the payor of last resort, meaning that all other available alternate resources, including IHS facilities, must first be used before payment is expected. These mechanisms enhance the IHS to stretch the limited PRC dollars and designed to extend services to more Indians. This renders the PRC program to authorize care at restricted levels and results in a rationed health care system,” writes the Indian Health Service on its website.

The First Step

The first step to accessing these funds is for an Oyate Health Center provider to issue a referral for medical care to the PRC program on behalf of the patient. The referral is reviewed by a team of PRC experts who determine the medical priority called the Managed Care Committee

In cases of emergency, a 72-hour notification to the PRC program must be submitted by the individual, provider, hospital, or someone on behalf of the individual. When an individual who is eligible for PRC coverage visits a Monument Health Emergency Room, that particular facility notifies the Oyate Health Center of the visit, however, patients should still notify the PRC program. 

Eligibility criteria for PRC Coverage at Oyate Health Center

• Enrolled tribal citizen or descendent residing within Pennington County
• Member of another federally recognized tribe residing in Pennington County with a social or economic tie to the Oglala Sioux Tribe, Rosebud Sioux Tribe, or Cheyenne River Sioux Tribe.
• Member or descendent of another federally recognized tribe residing within Pennington County
• Students who meet eligibility guidelines at their permanent residence prior to leaving for school.  Students must supply purchased referred care service application with a copy of full-time student status each semester
• Eligible patient that leaves the community, may continue to be eligible for 180 days
• Non-Indian women pregnant with an eligible Native American child for the duration of pregnancy through post­partum. NOTE: The Father’s Acknowledgment form must be signed prior to receiving Purchased referred care Service funds.
• And the services must meet medical priority as determined by the committee. 

All patients seeking Purchased Referred Care Service funds must:

• Provide proof of tribal affiliation. Acceptable forms of tribal affiliation include:
  • Tribal identification cards, and/or descendent letters.
• Apply for alternate resources for care. Examples of some alternate resources include:
  • Medicare
  • Medical Assistance
  • Disability,
  • Kinship Care
  • Express Enrollment for Pregnant women and children
• Proof of Residency in Pennington County

Appeal Process

Any person to whom PRC services are denied shall be notified of the denial in writing together with a statement of the reason for the denial. This denial will reach the patient within 30-days.

Should you be denied for Purchased Referred Care coverage there is an appeal process available to patients of the Oyate Health Center. You can appeal your initial denial letter to the Chief Health Administrator, then to the CEO of Great Plains Tribal Chairmen’s Health Board, and lastly the GPTCHB governing board. 

American Indian & Alaska Natives requesting an Indian Health Service (IHS) or Tribe*, Purchased/Referred Care (PRC) program (formerly known as Contract Health Service/CHS) to pay for their referred or self-referred care must meet all of the requirements at 42 C.F.R** 136.

*Tribes that contract with the federal government for the IHS’s Purchased/Referred Care function. 

**Code of Federal Regulation.

 Basic PRC Requirements:

Provide proof of enrollment in a federally recognized tribe; OR, proof that you descend from an enrolled member of a federally recognized tribe.