Medical or dental care provided at an Indian Health Service (IHS) or Tribal health care facility is called direct care. The Patient/Referred Care (P/RC) Program is for medical or dental care provided away from an IHS or Tribal health care facility. P/RC is for services provided by private doctors and hospitals that IHS/Tribal clinics are unable to provide.

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P/RC follows the Code of Federal Regulations Title 42 Subpart B 136.11 – 136.14, Subpart C 136.21 – 136.25, Subpart D 136.30 – 136.32 and Subpart G 136.61, the Indian Health Service CHS Manual part 2 chapter 3, and other rules and laws per our 93-638 Contract.

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P/RC is utilized in situations where:

• No tribal or IHS direct care facility exists.

• The IHS or tribal direct care facility cannot provide the required emergency and/or specialty care.

• A patient’s alternate resource(s) is not enough to cover the total of required care. See below for an explanation of “alternate resources.”

• The service is determined to be within established medical/dental priorities.

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The P/RC program is not:

• An entitlement program (such as Medicare or Medi-Cal)

• An insurance program

• An established benefit program

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After Hours Dental or Medical Services (Emergency)

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If you have an emergency need to access dental or medical services while the SIHC offices are closed:

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1. Call 911 or visit the emergency room if the situation is a true emergency. Emergency Rooms are for true emergencies, not for care that can be provided by primary care providers or because it is more convenient. Use of the emergency room will be reviewed for urgency of the service(s) provided.

2. Call SIHC Patient/Referred Care (619-445-1188) extensions 146,147 or 148 and leave a message with the following information:

   • Your first and last name

   • Your date of birth

   • Your phone number or another number where you can be reached

   • Date and time

   • Reason for dental or medical treatment

3. You will be contacted by P/RC staff during regular business hours.

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Some common reasons why P/RC will deny payment from an outside provider:

• No prior notification/authorization of service

• No 72-hour notice of an ER visit

• No medical record established at Southern Indian Health Council, Inc.

• No P/RC eligibility on file

• Non-emergency use of emergency room or ambulance

• Service is not within the current medical or dental priority level

• Patient is in custody of law enforcement or another State agency

• Patient left the hospital against medical advice

• Visit occurred as a result of a motor-vehicle accident. Vehicle insurance must be billed first.

• Alternate resources must be billed before P/RC can consider payment. You failed to apply for alternate resources.

• You could have utilized the Tribal Clinic for the service(s) provided.

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