Eligibility is determined through
- IHS Rules, Regulations, and Policies listed in the Federal Register 42 CFR Parts 36 and 36A
- IHS Purchased/Referred Care Manual Procedures
- Individual Tribal Policy and Procedures
Verified by Purchased/Referred Care (PRC) PRIOR to referral out and authorization for payment is granted with a purchase order to be presented at outside agency patient registration.
Purchase Order System
- Patient has been determined eligible for Purchased/Referred Care Services.
- Verification from provider referring patient to an outside agency for services.
- Appointment date and time is set by provider after speaking with PRC.
- Purchase Order is issued to patient to take to the appointment with them or can be faxed/emailed prior to appointment.
- Patient must present purchase order upon registration for appointment at outside agency they are advised to bring proof of other insurance with them as well.
- Outside Agency patient registration screens for additional health care coverage.
- Outside Agency patient registration presents purchase order to outside agency billing department for processing.
- Outside agency billing department bills all other insurances and then sends the UB92 or HCFA Forms with the purchase order to the Purchased/Referred Care Office for payment.
Please note: Per IHS, PRC is a payor-of-last-resort. All other resources must be utilized first.
- Upon receipt of invoice or bill please turn into PRC, however if you followed the purchase order system the outside agency would have submitted the bill to PRC rather than to you. If the patient did not follow the purchase order system, payment can be denied and the patient will have complete liability.
- Total processing time from when Purchased/Referred Care receives a claim with the purchase order approximately 1-3 weeks.