Through PRC, the Siletz Tribe can buy services that are unavailable at the Siletz Clinic or other IHS facilities. Please read the Purchased/Referred Care (PRC) Users Guide for a list of situations where PRC would be used, eligibility requirements and more.
Introducing the Medical Review Panel: Clarifying Our Process for Specialty Care Referrals
We’ve updated our Gatekeeping Process to the Medical Review Panel to avoid any confusion with the after-hours service called Gatekeepers. Our aim remains unchanged: to carefully review the medical charts and treatment plans referred to specialty providers before issuing an authorization number from PRC. This ensures everything aligns with our medical priorities.
This adjustment is intended to simplify the process for our Tribal members seeking specialized medical care. Should you have any questions, please feel free to contact our team at 541-444-9677.
Hours
Monday, Tuesday, Thursday & Friday
8:00 AM – 4:30 PM
Wednesday
12:00 PM – 4:30 PM
Contact
Pre-authorization and notification within3 business days is required.
Phone: 541-444-9677
Fax: 541-444-9645
Email Option
You can now receive your Patient and Referred Care (PRC) Pre-Authorizations and send your billing inquiries to SiletzPRC@ctsi.nsn.us.
Pre-authorization and notification within 3 business days is still required.
In your email include the following information:
- Subject (ex: Authorization number or Billing Inquiry)
- Name of Clinic
- Name of Provider
- Date of appointment
Emergency Room Gatekeeper
During regular business hours, call the Siletz Clinic. After regular business hours, on weekends, or holidays please call 800-648-0449 or 541-444-1030. You will be directed to the answering service, the physician on call will be alerted.
Staff
Selina Rilatos
Healthcare Reimbursement Technician II
Christine Knott
Healthcare Reimbursement Technician II
Joella Strong
Healthcare Reimbursement Technician I
Monica Wolf
Healthcare Reimbursement Assistant
Shay Robertson
Healthcare Reimbursement Assistant
Questions Commonly Asked
Why didn’t PRC pay a bill I mailed to them (or dropped off at clinic)?
The facility MUST send a bill PRC directly. The facility will send the bill on an appropriate claim form (a UB-04, CMS-1500 or ADA) that provides necessary details to process a claim. If you get a bill, please contact the facility and ask them to bill PRC as your secondary (or primary) insurance. Although PRC is a benefit and not an insurance, the billing process is the same.
Why does it take so long for PRC to pay my bill? My doctor’s office said they’ve sent 3 claims.
There should only be a delay if we’ve never paid the provider before. PRC requires the facility to provide a W-9 tax form before a payment can be made. After receiving a W-9 from a facility, PRC then performs a TIN (Taxpayer Identification Number) match with the IRS. If a TIN match cannot be made then the W-9 is rejected and a new form is then requested.
What do I do if I get a bill that PRC should pay – I have an authorization #?
Notify the facility that they need to bill PRC – ASAP.
What types of visits needs to go through the Medical Review Panel?
All visits for Specialty Care and Imaging.
Why did my visit get denied by PRC?
This can happen for several reasons. The most common reason is that it was not called in to PRC.
How can I prevent bills from being denied?
Call your visit in as soon as you know that you have an appointment. This will ensure PRC has time to verify that your annual update is completed, you have applied for or shown that you are over income for Oregon Health Plan, and to confirm if the visit needs to go through the Medical Review Panel.
How to Avoid Denials with PRC
- Make sure you have completed an annual update. If you are not sure you are due for an update, then you probably are.
- If the patient benefit coordinator reaches out for Oregon Health Plan information, please respond. If you do not have other insurance, you will not be required to pay for it, but if you qualify for OHP, then you must apply for it. If you do not participate with the patient benefits coordinator, you will not be eligible for services until that has been done.
- Call in all visits in to PRC immediately after the appointment is created or changed.
- Specialty care must go through the Gatekeeping Review Committee. Once you have received your approval letter in the mail, schedule your appointment then call Purchased Referred Care for your authorization number. Specialty care is anything that cannot be done at your Primary Care Providers office.
Important Notice for PRC Eligible Tribal Members
All tribal members residing within a 40-mile radius of an Indian Health Services (IHS), Tribal Health Clinic, or Urban Indian Health Center are required to access their Medical, Dental, and Vision care exclusively through one of those facilities.
If you’re uncertain about whether you fall within the 40-mile radius, please don’t hesitate to reach out to Siletz PRC using the contact details provided above.
Here are the contact numbers for the designated facilities:
Siletz Community Health Clinic: 1-800-648-0449
Chemawa Health Clinic: 1-800-452-7823
Grand Ronde Health & Wellness Center: 1-800-422-0232
Ko-Kwel Wellness Center: 541-916-7025
NARA NW Wellness Center: 971-279-4800
NARA NW Dental Clinic: 971-347-3009
NARA NW Indian Health Clinic: 503-230-9875
It’s really important to use these specific healthcare facilities for your needs. When you get your healthcare at these places, you don’t have to worry about paying for your care, and you don’t need special permission to get it. Plus, by using these facilities, we help PRC save money for other important health services that a tribal member might need in the future. It’s helping out our community by making sure everyone can get good healthcare. Let’s all make an effort to use these places for our healthcare needs. Thanks for understanding how important this is for all of us.
Alternate Healthcare Benefits
Let’s explore the alternate healthcare benefits available to enrolled Siletz Tribal members:
Who’s Eligible
All enrolled Siletz Tribal members have access to these benefits. However, dependents and descendants are not eligible. To get started, make sure you’ve completed an individual registration application and updated it with the Siletz Community Health Clinic.
What’s Available
You have access to acupuncture, chiropractic care, naturopathic services, and massage therapy. These benefits are available four times per year, at the start of each quarter, depending on funding availability. It’s first-come, first-served, so don’t wait! Simply contact PRC and request the benefit you’d like to use.
What to Expect
After contacting PRC, you’ll receive a letter detailing your eligibility, the number of visits allowed, and the benefit amount. This letter also contains information to share with your provider for payment processing.
Here’s the Breakdown
Each patient can have a maximum of 3 visits per quarter, up to $75.00 per visit, per quarter.
Any expenses exceeding this limit become the patient’s responsibility.
Your well-being is important to us, and we’re here to help you access the care you need. Reach out to PRC today to kickstart your journey toward holistic health!
Health Benefits for Out-of-Area Members
Discover the special health benefits waiting for Tribal Members living beyond the 11 county service area! From January 1, 2024, to December 31, 2024, the Tribal Council has designated extra resources just for you. If you’re a Tribal Member residing outside our 11-county service area and you are registered for healthcare with the Siletz Tribal Health Department, you’re eligible!
You can receive up to $2,000.00 annually for combined dental and medical needs. Plus, there’s more assistance available, including pharmacy, cataract surgery, and hearing aids! And here’s a perk: if you’re an elder, a child, a student, or diagnosed with diabetes, you might qualify for vision benefits annually!
Here’s what’s available:
- Pharmacy: Receive up to $500.00 annually
- Vision: Receive up to $450.00 every 2 years
- Hearing Aid or Cataract Surgery: Receive up to $2000.00
- (Note: Hearing aids can be authorized every 3 years.)
Remember, pre-authorization is required for all benefits except pharmacy, so reach out to us. The authorization lasts for the entire year, but it doesn’t carry over to the next, so act promptly!
For inquiries or to access your benefits, simply call PRC at 541-444-9677. And when you’re ready have your providers submit your claims,
They can be faxed to:
541-444-9645
or
mailed to:
SCHC Attn: Siletz Purchased/Referred Care
P.O. Box 320
Siletz, OR 97380
Don’t let these valuable benefits pass you by! Contact us today to learn more!
Caremark (Pequot) Pharmacy Card & Reimbursement Information
Regardless of where you live, your pharmacy benefit is $500.00 per year. Every January 1st your card renews. Members that live in the 11-County Service Area should have your maintenance medication mailed to you through the Siletz Community Health Clinic (SCHC) pharmacy. Not all medications are in the SCHC formulary, so that is when you would use you pharmacy card at a retail pharmacy such as; Walgreens, Fred Meyer, Rite Aid etc. . . .
Members that live outside the 11-County Service Area (Direct Care) are not able to get medication mailed through the Siletz clinic, but are able to get medication directly through Pequot Pharmacy. Any maintenance medication needed by Direct Care patients should be mailed to Pequot directly this will stretch your card dollars.
Patients that have primary pharmacy insurance, such as Medicaid, Blue Cross Blue Shield, AETNA, Medicare Part D etc… and have to pay a co-pay up front to the retail pharmacy, can be reimbursed up to the $500.00 per year. Members that pay up front for medication, and still have a balance on their pharmacy card, can be reimbursed as well.
To receive a reimbursement you must provide the receipt from the pharmacy, not the cash register receipt. The receipt must have: Your Name, Dr. Name, Date of Service, Medication Name, Medication Dosage, Amount Paid. Mail your receipt to
Purchased Referred Care
PO Box 320
Siletz, OR 97380
Your pharmacy card should not have you Social Security number on it. If the card has your Social Security number on it, then you need to contact Selina Rilatos with PRC at 541-444-9677 to get a new card, or email her at SelinaR@ctsi.nsn.us. You will be required to have an updated Individual Registration form on file in order to receive your new card.
You can fill out the Reimbursement form linked above and send it directly to Pequot if you would like. If you need assistance in filling it out, you may send it to PRC staff for help. Please note that it may take longer to receive reimbursement if you send it to PRC staff first.
Mental Health Services
Services Available
- Counseling Services – individual or family
- Psychiatry Services
- Psychology Services
- Up to 8-visits annually (more if medically necessary)
Eligibility
Siletz Tribal Members are eligible for Purchased/Referred Care (PRC), formerly Contract Health Services (CHS).
How to Get Benefits
Call PRC at 541-444-9677. Prior to making an appointment with a provider, confirm the provider will accept PRC as payment. Benefits are limited and on a first-come, first-serve basis.
What You Need to Know
After calling PRC for benefits, the patient will receive a letter with program details. The letter also provides information that the patient can give to their provider for payment processing information.
You will not be required to use other resources first. This will allow you to go to a provider that does not accept Oregon Health Plan/Medicaid or your private insurance.
Also Available for Siletz Tribal Members
Medicare Reimbursement
The Siletz Tribe reimburses any Siletz Tribal member for their Medicare B (Hospital) and D (Pharmacy) premiums.