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 within 3 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.
Effective July 1st Through December 31, 2024
All PRC Eligible Tribal members will be allowed to schedule with outside dentists for the next 6 months.
Chemawa, Grand Ronde and the Siletz Clinic dental departments being backed up and short providers for dental, you will be allowed to go to your own dentist without a referral. You will still need to call PRC for an authorization number, and treatment plans from the providers will still be required.
Please contact PRC for more information at
541-444-9677 or email at SiletzPRC@ctsi.nsn.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
No matter where you call home, you’ve got a pharmacy benefit of $500.00 per year waiting for you. Your card renews every January 1st, so you’re always covered. If you live within our 11-County Service Area, you can have your maintenance medications mailed to you from the Siletz Community Health Clinic (SCHC) pharmacy. But if your meds aren’t on their list, no worries! You can use your pharmacy card at other places like Walgreens, Fred Meyer, Rite Aid, and more.
Now, for our members living outside the 11-County Service Area (Direct Care), you won’t be able to get your meds mailed from the Siletz clinic. Instead, you can go directly through Pequot Pharmacy. Simply have your maintenance medications mailed to Pequot to make the most of your card dollars.
Got primary pharmacy insurance like Medicaid, Blue Cross Blue Shield, AETNA, or Medicare Part D? If you have to pay a co-pay upfront at the retail pharmacy, you can get reimbursed up to $500.00 per year. Even if you’ve paid upfront and still have money left on your pharmacy card, you can still get reimbursed.
To get your reimbursement, send the receipt from the pharmacy (not the cash register one) with your name, doctor’s name, date of service, medication details, and amount paid to:
Purchased Referred Care
PO Box 320
Siletz, OR 97380
Quick tip: Make sure your pharmacy card doesn’t have your Social Security number on it. If it does, reach out to Selina Rilatos with PRC at 541-444-9677 or email her at SelinaR@ctsi.nsn.us to get a new card. You’ll need an updated Individual Registration form on file to receive your new card.
Need a Reimbursement Form for Pequot?
You can fill it out and send it directly to them. If you need a hand with it, don’t hesitate to reach out to PRC staff for assistance. Just keep in mind, it might take a bit longer to get reimbursed if you go through PRC staff first.
Mental Health Services
What’s Available
- Counseling Services: Whether you need support individually or with your family, we’ve got you covered.
- Psychiatry Services: Expert help is available for those who may need medication management or more specialized care.
- Psychology Services: Dive deep into understanding yourself and overcoming challenges with our psychology services.
- You can have up to 8 visits annually, and even more if it’s medically necessary.
Who’s Eligible
Siletz Tribal Members qualify for Purchased/Referred Care (PRC) who live within the 11-county service area.
How to Access Benefits
Give PRC a call at (541)444-9677. Before scheduling an appointment, make sure your provider accepts PRC as payment. Benefits are available on a first-come, first-serve basis, so don’t hesitate!
What You Need to Know
Once you’ve contacted PRC, you’ll receive a letter with all the program details. This letter also includes information that you can share with your provider for payment processing.
And Here’s the Best Part
You won’t need to exhaust other resources first. You’re free to choose a provider even if they don’t accept Oregon Health Plan/Medicaid or your private insurance.
Your mental health matters to us, and we’re here to support you every step of the way. Give us a call to get started on your journey to wellness!
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.