Referrals/Purchased Referred Care

Purchased Referred Care

About Purchased/Referred Care

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.

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.

To learn more, click here.

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.

The P/RC program is not:

• An entitlement program (such as Medicare or Medicaid)
• An insurance program
• An established benefit program

After Hours Dental or Medical Services (Emergency)

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

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.

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.

Frequently Asked Questions:

1. What are “Alternate Resources?”
   • Alternate resources are health care resources other than those of the IHS. Such resources include health care providers, institutions, or health care programs for the payment of health services including, but not limited to programs under Titles XVIII and XIX of the Social Security Act (i.e., Medicare and Medicaid, State Children’s Health Insurance Program), State and local health care programs and private insurance. Examples of alternate resources include:
     • Medicare
     • Medicaid Program
     • Veterans Benefits (Champus, Champva)
     • Private Insurance (such as Blue Cross Blue Shield, Cigna, etc.)
     • Homeowner’s Insurance
     • Children’s Rehabilitative Service (Crippled Children’s Services)
     • Auto Insurance (liability)
     • Workman’s Compensation
     • State Vocational Rehabilitation
     • State Maternal and Child Health Programs
     • Utilizing the Southern Indian Health Council is considered an alternate resource
     • If you are a student and your education grant includes funds for health services, you will be expected to use the grant funds to purchase available student health insurance.

2. Why do I have to apply for Alternate Resources?
   • This is required by 42 C.F.R. 136.61, Payor of last resort. Approval of P/RC payment for services is considered after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to apply for the alternate resource. The Southern Indian Health Council Clinic is considered an alternate resource also.

3. Why did my bill not get paid?
   • Each visit to a non-IHS health care provider and the associated medical bill is distinct and must be examined individually to determine P/RC eligibility. All P/RC requirements must be met for each episode (treatment) of care. A patient must meet residency, notification, medical priority of care and use of alternate resources requirements of 42 CFR 136.23, 136.24 and 136.61 in order to be eligible for P/RC. Example: If a P/RC authorization is issued, IHS will pay the first medical treatment. Follow up care or additional medical care are to be done at the nearest accessible IHS or tribal facility; or will require approval with a new P/RC authorization. If this process is not followed, the patient may be responsible for the expense.

4. An SIHC doctor referred me to a specialist, why am I being held responsible for the bill? 
   • Referrals are not a guarantee for payment. A referral is a recommendation for treatment/test only. The P/RC program must review the referral to make the determination for IHS or tribal approval of payment. All P/RC eligibility requirements must also be met. See 42 C.F.R. 136.23, 136.24 and 42 CFR 136.61