Purchased Referred Care (PRC)

  • What kind of program is PRC?
    PRC is a program that helps eligible American Indian patients get the necessary special health care service (needed) that is not available at TCRHCC or any IHS.
  • I thought PRC was my IHS insurance and covered my medical expenses whenever I left the reservation?
    PRC is NOT an IHS insurance program.
  • What about U.S. Treaty obligations? Does this include health coverage?
    IHS does not cover payment for all medical services a patient wants or receives. They provide primary (direct) care (at no cost) at the local IHS/638 facilities. Through PRC, the IHS covers only certain necessary services.
  • Why does PRC have so many requirements?
    PRC funds are limited; our tribes are increasing in number which means we have more people who require special health care services that are not available at TCRHCC. These laws make sure all patients receive consistent and fair treatment.
  • If I meet four of the five eligibility criteria, will you let me slide?
    No. Each individual requesting for PRC assistance must meet all five eligibility criteria.
  • Why do I have to apply for medical insurance to be eligible for PRC?
    If you are eligible for some type of medical insurance and use it, then PRC will have more funds to help more patients for a longer time.
  • What if I don't qualify for PRC, how do I pay my medical bills?
    The PRC staff will assist refer you to a Patient Benefit Coordinator (PBC) to apply for the Arizona state medicaid program, AHCCCS or any other program you may be eligible for.


Eligibility Criteria

There are five eligibility requirements that the patient must meet..

1. Indian Decent
The patient must be a member of the Tribes served by the local Purchased Referred Care Service Delivery Area (PRCSDA). TCRHCC PRCSDA serves members of Navajo, Hopi and San Juan Paiutes.

You must be a Native American with a verified tribal census number or Certificate of Indian Blood (CIB).

A non-Indian woman who is pregnant with an eligible Indian's child is eligible for care during pregnancy and six weeks postpartum.

2. Residency
The patient must live within the TCRHCC PRCSDA:

      • Tuba City, Moenkopi
      • Trust land and counties that border the Indian reservation.

3. Medical Priority
You must be receiving care for a condition that meets the TCRHCC Medical Priority and Necessity
guidelines. Only life-threatening and limb threatening situations are emergencies.

If you go to a non-IHS hospital Emergency Room for something that is not an emergency (like a cold) this will not meet medical priority.

4. Alternate Resources
PRC is considered Payor of Last Resort and secondary to all other alternate health resources, i.e., Medicare, Medicaid, private insurance, etc.

You must apply for and use any other alternate health care resources available to you before PRC funds can assist with the payment of any Non-IHS provider/facility health care bills. This includes: Medicare, State Medicaid (AHCCCS, Utah/Colorado/New Mexico) or private insurance.

5. Notification / Prior Authorization
PRC must be properly notified when a patient has or will be obtaining medical services from a non-lHS provider/facility:

Notification occurs after the emergency service

  • Emergent- PRC must be notified within 72 business hours from the time the patient received treatment or was admitted. For an elderly & disabled person(s), the notification timeline is within 30 business days.

Prior Authorization occurs before service is provided.

  • Non-Emergent -  The patient must obtain prior authorization (approval) from PRC for all appointments scheduled by a non-TCRHCC physician before getting treated.
  • If the nearest health care facility is an IHS facility but you chose to go to a Non-lHS facility, PRC will not pay for your emergency care.

How PRC Determines Payment

PRC makes their decisions to approve or deny payment based on Medical Priority, Eligibility, and Availability of Funds.

PRC Authorization Process. The diagram illustrates the process involved with PRC determination.

Important Points to Remember

  • A TCRHCC Patient Referral is not a guarantee for payment and does not mean you automatically qualify for PRC benefits.
  • To be eligible for PRC, an individual must meet all eligibility requirements.
  • PRC is not obligated to pay for medical services unless funds are available and authorized.
  • PRC is not an entitlement program and not everyone is eligible.
  • Eligibility requirements are stricter for PRC than they are for direct care.
  • Federal regulations require proper notification (emergent, non-emergent care).
  • Take all necessary medical information along with your referral when you go for your appointments.
  • Any personal request (via phone, fax, letter, etc.) for a patient referral before a scheduled appointment or after the appointment is not an authorized referral and will be denied by PRC.