Andrea Taylor from the Public Information Department interviews Selina Rilatos, Healthcare Reimbursement Technician II with Purchased/Referred Care (PRC)
Links
Annual Update: Microsoft Word – Annual Update (Feb2025)
Patient Portal: PxP Portal
Pequot Reimbursement Form: Pequot-Reimbursement-Form.pdf
Website: Healthcare | Confederated Tribes of Siletz Indians
Transcript
Andy
Hello everybody. My name is Andrea Taylor and I’m the public relations specialist for the Confederated Tribes of Siletz Indians. And today I have Selina Rilatos.
Selina
Hi Andy, I am with Siletz Purchased Referred Care. I have been back in Purchased Referred Care since 2021 and that was my very first job with the Siletz Tribe in 1997. So I have been working within the health department for a long time.
Andy
Just a few minutes.
Selina
Just a few.
Andy
All right. And let’s dive into our topic today. We’re talking about, as you said, Purchase Referred Care.
Selina
So Purchase Referred Care used to be called contract health services. And somewhere in the 20 years that I was away from contract health, it was changed to Purchase Referred Care by the federal government. To my understanding, was to be able to differentiate between contracted in contracted services and purchase services.
Andy
Okay, so what is PRC then?
Selina
I’ll start kind of start from the beginning. Purchase Referred Care is a payer of very last resort. So a tribal member who comes to the clinic or goes outside of an IHS facility, whether they have insurance or not, they still have to have, we obligate funding for that. And so, we pay. We can pay full balances and we pay secondary balances.
Selina
That’s how that works.
Andy
And a secondary balance that’s like if you have insurance.
Selina
If you have a primary insurance. Yes. And like say any like say even the tribe’s regular insurance, our HMA or Medicare, we will pay the deductibles and the remaining balances or the co-pays.
Andy
Okay. Thank you for that. So, who’s eligible for PRC?
Selina
So to be eligible for PRC, you must be an enrolled member of the Confederated Tribes of Siletz Indians. That’s the first one. The second one is you can be a member of another federally recognized tribe and live on tribal trust land. Children, dependents, if they’re enrolled or not, are eligible for PRC services through the age of 19. Once a child turns 19, if they are not eligible for tribal enrollment, then they become direct as they will only be a descendant, so we will cover their services inside an IHS facility, but outside services will not be covered.
Andy
All children?
Selina
Children, biological children, foster children, adopted children, are covered.
Andy
Tribal household children.
Selina
Yes. They must be in the tribal household. Yes.
Andy
Okay. And where does PRC funding come from?
Selina
PRC funding comes from Indian Health Services, which is a federally recognized department. And it’s not a never-ending pot of funds. It’s based on, our tribal enrollment and our numbers determines what we get for that funding. And it, is it’s based on medical priorities on how it is spent out. So like right now, PRC is operating on a level, level, tribal level, priority level one, which is imminent death. You have to be seen a fracture that you must be seen for down to a priority level four, which is you know, sometimes like a knee surgery that maybe might not be, it could be put off longer if need be. But if we have, as long as we have the funding, we can cover that. And I know with things right now people are wondering, are we going to be covered? What’s going on? Because of the uproar with what’s going on in the federal government right now. But right now, we are still operating at a level four. Okay. So, a lot of services are covered.
Andy
All right. And you’ve already kind of touched on it, but what services does PRC cover?
Selina
So PRC services will cover. So, let’s start with just the patients that come to the Siletz clinic or an IHS clinic. First. If, you see a provider at your local IHS clinic, which would be Siletz possibly Coquille in Eugene, Grand Ronde in Grand Ronde and Chemawa in Salem with their services that they cannot do at those facilities, they will refer you out and that will we can cover that. But there also is a process depending on if it is a specialty care and specialty care would be orthopedics, rheumatologist, specialists, those and those go through a separate process. You know, if they’re sending you out for an X-ray, we will cover that. That does not need a special process to be covered, but the tribal member still needs to contact PRC and let us know that that’s why we were sent out.
Selina
This is where we’re going, and this is what we’re doing.
Andy
Okay.
Selina
Yeah. So, then that goes for both medical and dental services as well.
Andy
What are some of the requirements to utilize PRC both in and out of area?
Selina
So to be eligible to use PRC services you must have an annual update. So, let’s say you updated in January of 2024. Well, your update is due in January of 2025. That is the biggest one to be eligible for services. The second one is if you do not have a primary insurance. We will not make you buy one, but you must apply for or show that you are over income for Oregon Health Plan and that those are the two, really two of the biggest ones that will determine the requirements and how you can use the program.
Andy
What is an update?
Selina
An update is a, it’s just to make sure, we want to make sure that you’re still at your same address. You still have the same insurance, the same phone number, email address, all of that.
Andy
That’s like the clinic form that they give you annually.
Selina
Yes.
Andy
Okay.
Selina
Yes. And that goes and we send that out to our out-of-area patients as well. And it can also be done too if you call in from Portland or Phoenix, you we can have you talk to our front desk staff and they can update you over the phone as well.
Andy
Oh, that’s, that’s super nifty.
Selina
It is. It comes in very handy, especially when you have a patient on the phone who you’re looking and like, oh I see you’re due for an update, “Can I send you down to the front desk and let them update you real quick over the phone?” And then they can send you back up and then we’re all good.
Andy
So that’s a form that’s on the website.
Selina
Yes it is. Annual Update (Feb2025)
Andy
Okay. So, somebody could download that on their own and mail that in.
Selina
Yes they can, they can mail it.
Selina
Fax it
Andy
Email it
Selina
Email it.
Selina
Yes.
Andy
Perfect. Okay. That was my next question.
Selina
Yeah. Email has been a lifesaver.
Andy
It’s been wonderful. All right. So then how do we get ahold of PRC and what do we do when we don’t hear back?
Selina
So to get Ahold of PRC, there are several different ways to reach PRC. One is, by calling, in which the phone number is (541) 444-9677. We have recently kind of changed the phone procedure. So, if all of our, technicians are on the phone with other patients, it rolls over to our business office clerk who will answer the phone so you can talk to a live body, and they can take a message and give it to that person that you need to talk to or want to talk to. And then we can get you called back. The other way is, by email. Emails are definitely a lot faster, I believe. And that’s just me. Because I get a lot of them. And if you don’t hear back, you know, shoot us an email or give us a call back, because sometimes, you know too, and I know with voice mails, at times too things can get lost down in a shuffle very easily.
Andy
What is the PRC email?
Selina
The PRC email is siletzprc@ctsi.nsn.us
Andy
Okay.
Selina
And that goes to the whole PRC group. So, if you’re hoping maybe one person is going to get you and maybe that person is not available, somebody will return that email or respond to you.
Andy
That’s a group all PRC.
Selina
Yes.
Andy
Email.
Selina
Yes.
Andy
Okay. And that’s only going to PRC. That’s not going to everybody?
Selina
No that Just goes strictly to Siletz PRC. It does not go to anybody else in the tribe. And then we also have a Patient Portal, which that is not my strong point. I will say that, but that is another way. If you are a registered patient at the clinic and you need to reach out from, you know, from, from whichever area you’re in and you’ve already signed up for it, then that’s another way also.
Andy
Yeah, the patient portal is great. I use the patient portal pretty often just to shoot a note out to the doctor. Try to schedule an appointment or just check on other upcoming appointments because they’re all listed there.
Selina
Yes they are. And it’s very handy. But not a lot, I mean, I don’t think it gets as much use as we’d like for it too. And if you’re interested in trying to figure out how that’s going to work, reach out to somebody in PRC. And if you have an email on file with us, we can send you the link to sign up for that.
Andy
Perfect. Thank you. So, what do we do with our bills if they go unpaid by PRC?
Selina
So a lot, there, there are different factors that go into bills not being paid with PRC. The big one that I have found is let’s say you go to a provider’s office for a procedure, and so you might get a hospital bill, then there’ll be an anesthesiology bill, plus maybe a radiology bill, plus a physician’s bill or even a lab. And not all of these entities pass their information back and forth. And it’s very frustrating. So, the biggest one is if you’re getting a bill from, whether it be the hospital, a doctor’s office, call the number on that bill and ask them, do you have our information? You’ve I see you’ve built my primary insurance, but you’re still sending me a bill. Why have you not, why haven’t you billed PRC? And it more than likely is that they don’t have that information or, yeah, it wasn’t put there to say that, Hey, we have a secondary. So, the first and first thing you need to do is to call that number. And if that does not get you anywhere then please by all means you can bring us your bill and we can help you with that. To get what we need in order to, to get that claim paid. The other one of the reasons to why sometimes things don’t get paid by PRC is the process was not followed. That means that maybe you did not call in for your authorization number. Or you called and got the authorization number and then gave us a date that you were going and then didn’t go, but you went… Maybe you went later. So, if your appointment times change and you have an authorization number, call us. Say, hey, my appointment was scheduled for March 14th and now they’ve moved it out to March 17th. So, if you call PRC or even email us and let us know that the date change, we can reflect that in our system. So, the authorization number will match the data service.
Andy
Does the time change? So, let’s say it’s at 10:00.
Selina
No.
Andy
On the 14th. But they’re like, we can’t actually see till 1230.
Selina
No, no. Yeah. Time doesn’t change. I should, date. But I mean yeah date matters. Time doesn’t.
Andy
Okay.
Selina
And it could be to let’s say you go to, you know, the hospital for X-ray or a lab or something like that, or you’re scheduled for two things at the on the same day, at the same place. They may come in two different bills. And that is absolutely okay as long as you’re letting us know that, hey, I’m getting my mammogram done to today, but I’m also getting a Dexa scan done or I’m getting a CT scan done because they will come billed separately.
Andy
Okay. Is that two separate authorization numbers for those?
Selina
And it can be one authorization number. But we just need to know that you’re having both things done at the same time. And we,
Andy
You put it on, on your end.
Selina
Yes, we noted on our end. So, we can get you covered. The other one is out of area patients. And that is a tough one, because when you’re going to a provider’s office out of state, sometimes getting the information that we need from them is difficult. Whether it be a medical claim form, an explanation of benefits from your insurance or a W9, which is for tax purposes, so we can put you so we can issue a check. Those are that’s a big one.
Andy
Okay. So, you had discussed getting an authorization number. But how do we get an authorization. Like what do we do.
Selina
Okay. So, the process for getting an authorization number and the big one and the biggest takeaway from that is as soon as you know the date of your appointment, call PRC, which is the (541) 444-9677 or email us. And then you need to let us know where you’re going, when you’re going it doesn’t have to be a detailed explanation of why. It could be I am going to go see doctor So-and-so for my yearly for my exam, or I’m going for physical therapy. And so, at that time then we will take that information, we will put it into our system, and we will obligate a certain amount of dollars towards each visit. So, it’s just a matter of calling us or emailing us and letting us know. But we will give you an authorization the same day, if that’s what you’re doing. But it really helps if you don’t call us or email us or text us on the way to your appointment, which we get a lot of that.
Andy
Okay.
Selina
And sometimes it’s, you know, somebody might be on the phone and the phones are tied up and we can’t get to you right away. And that could affect your visit at your provider’s office, because sometimes some providers will not see a patient without that authorization.
Andy
All right.
Selina
There’s a lot of providers that we use that know that.
Andy
Right.
Selina
And some providers will call us for the number, which is very handy. But not all.
Andy
Not all. I’ve had it where where I, I was trying to schedule my son an appointment and they were like, we have an appointment availability tomorrow. And I was like, I don’t think that’s enough time for turnaround on that auth number. What else do you have? And unfortunately, it’s like a month out.
Selina
Right?
Andy
Yeah. But I would rather take that than be like trying to make my hurry your hurry.
Selina
Yes. Yeah, yeah, yeah. It comes down to, well that your emergency isn’t always my emergency kind of thing. But, you know, we, we try our best and we try. We do try our best to treat everybody the same, you know? And there are situations that will come up that are different. And we’re like, oh, what are we doing with this?
Selina
So you know, and sometimes research has to go into it
Andy
Right
Selina
To determine that. But the big one, too and I guess with authorization numbers comes in your gatekeeping requests, which are when a provider refers you to outside for, let’s say, an MRI, an ultrasound, a Cat scan, hearing tests, sleep medicine, anything that we cannot do at the clinics that are specialty care, that has to go through our gatekeeping review process, which is now a, called a Medical Review. And they meet weekly on Thursdays. Sometimes things come up and we understand that and that you may have to try to get in before we can get you into gatekeeping. And we can have the as long as we have the chart notes, we can get that reviewed and possibly say, yes.
Andy
Awesome. Okay, so what do I do and who do I call after an emergency room visit? So, I’ve been sick. Something has happened. I’ve gone to the emergency room. What is the process?
Selina
So the process for the emergency room visits are during, and the biggest one is during say Monday through Friday when you’re most medical offices are open, call and get triaged. Call whichever clinic office you have, call and get triaged if that might be something, they can get you into the clinic to see. Whether it be a nurse visit for a throat swab or, you know, or something like that. And we also have a, after hours line that can be called as well in for gatekeeping. And you call and you leave, the answering service will take down your information, and they will reach out to the on-call provider, and that on-call provider will call you back and they can say, you know, you what’s going on? And they can say, yes, go. Or, you know, why don’t we get you in? I want we can try to get you in tomorrow. And if that’s the case and if you feel like you need to go, you know, you can go. We can’t guarantee payment. And once you leave the emergency room, you have 72 hours, three days to contact PRC and let us know that you went
Andy
Business day? Or?.
Selina
Yes.
Andy
Okay.
Selina
I say business days.
Andy
Okay. So, it’s on a Friday night. Yep. And they call me to broke my leg in three pieces. And I go to the emergency room on Friday night. I can call on Tuesdays.
Selina
Yes. Okay. Absolutely. And so, and that like there creates a whole nother thing because then you go to the, say you go for the E.R. for a broken leg and therefore you need to go to orthopedics. That is something PRC approves automatically. You just need to call us and let us know.
Andy
Okay.
Selina
That is huge.
Andy
Okay. Can anybody call PRC for me?
Selina
They, Your husband could. Your, you know, if you’re unable to make that phone call, you’re spouse, your significant other if you need to your adult child.
Selina
You know, or if you’re at the hospital and they say we, we’re going to call PRC, I mean, I’ve received phone calls from patients who from, from providers, office of patients in the dental chair.
Andy
Okay.
Selina
Wanting to know, can we do this?
Selina
So yeah.
Andy
All right.
Selina
And let’s see. So, the biggest one too is I guess with the emergency room as well is that once we get those, they do go through, if we’ve referred you, generally, it’s always going to be approved. But there’s what we call an inappropriate use of the emergency room, which would be, I’ve had a cold for a week, two weeks. I can’t breathe, my throat hurts. I’m going to the E.R.. That could have been a clinic visit.
Andy
Right.
Selina
Or even, you know, even,
Andy
Urgent care.
Selina
Urgent care. Yes. And with inappropriate visits to the emergency room, we’ve kind of changed up that policy a little bit because we were finding that, you know, you get a child whose parents took him to the E.R. and it was deemed inappropriate. Well, before that meant you only got one in your life time. And so, is it fair to punish that child for their mom and dad taking them for something they really didn’t need to go? So, what we’ve done now is that from zero through the age of 18, you get one. And then once you, are, become an adult, then you get one. And if you get one, get that one inappropriate. We’ll send you a letter. We’re going to let you know that yes, we’re going to cover it this time. But if you receive any more that are deemed inappropriate use of E.R. funds, then that will be a denial of payment.
Andy
That’s good to know.
Selina
Yeah.
Andy
So try calling the clinic first. Always then.
Selina
Oh yes. Yes.
Andy
Try the afterhours number.
Selina
Yeah even the afterhours number. Absolutely. Because it could eventually save you money. That saves us money and you know makes our money go further.
Andy
Yeah.
Selina
Because the misconception is purchase referred care is an, it’s not an endless pot of funds.
Andy
So the next question I’ve got for you is what can cause a denial of PRC coverage? Because we’ve already kind of talked.
Selina
Yeah, yeah.
Andy
Let’s just go a little farther into that.
Selina
So, what can cause that is not having your updates, not having insurance, not calling us and letting us know that you had a visit. And that goes for regular your regular provider visits. If you live outside of the Siletz, Grand Ronde area, Portland, you don’t call us and let us know that, hey, I’ve got this appointment. This is when I’m going. That is a big one for denials and even gatekeeping referrals. Even though you were approved by our gatekeeping committee, the medical review panel, you still have to call in for that authorization and let us know the date you’re going. Because that’s the reason that we do that is because we obligate money to your visits. And so, if you don’t call, then there’s times where and it this happened in the past where we don’t have the funding to cover that because we don’t have that money obligated to that for that bill. And there’s been times where we’ve only operated at a level 1 or 2. So things have to be really, you really want to pay attention to that.
Andy
Okay.
Selina
Yeah. Really.
Andy
So can I appeal a denial?
Selina
Yes, you can. Yes, we do send out a letter that explains that to you, the date of service that you were denied for, why it was denied and it comes with different reasons. And there are sometimes two. We have to, you know, we can add in additional explanation, but there’s a 30 day process that you have to deny that or to appeal your denial, and you appeal that to, the health director, Miranda, watch those denials. I don’t, I personally do not issue denials. I do paying and then I do the research for Miranda to go, Did this patient call in? Is this tied to another bill and then give it to her? And she reviews it and then she makes that ultimate decision. I get that back. I will send you a letter.
Andy
So to appeal it, I can drop it off at the clinic or email it in the mail? All of the above? Okay.
Selina
Yep, you can mail it in. Yes, you can even mail it.
Andy
Okay.
Selina
Yep. You can email myself or Miranda or, Christine Marceau, who does a lot of the same job I do. But we do the research for her for Miranda. Okay. Because we’re the ones that kind of deal with the claims. Mostly we pay them and then we keep everything in patient files. So, we can go back and look, does this patient never call anything in? Do they want us to pay for everything, even though they didn’t call it in? Are they a first-time person, you know? And there’s different things to look at. Are you a first-time user of PRC? I know that personally with my own adult children, and doing all of their stuff for them as they were growing up, I’ve, I’ve guided them through what you need to do and, you know, with explanations of if you’re going to go to this dental office or what have you, this is what you need to do and make sure you have an authorization number when you go in. And that’s a big one. And we do have pamphlets that are available by email. I can email them out. We can mail them out. They are not yet. But we will try to get them because we do have to update some of the information with staff changes and everything, but they’re pretty much pretty basic and it doesn’t take much to update them. You can appeal every. If you get ten denials in a year, you can appeal every single one of them.
Andy
Okay.
Selina
And that’s a big one. And we do have pamphlets that are available by email. I can email them out. We can mail them out.
Andy
Is it on the website?
Selina
They are not yet. But, we will try to get them because we do have to update some of the information with staff changes and everything, but they’re pretty much basic and it doesn’t take much to update them.
Andy
I had a question in my head, over, how many appeals am I allowed to have?
Selina
You can appeal every, if you get ten denials in a year, you can appeal every single one of them.
Andy
Doesn’t mean you’re going be given it.
Selina
It does not mean. But you can appeal this. Yes, you can appeal that decision.
Andy
Is there a secondary appeal or is that the final?
Selina
Well, no.
Andy
Final one is the final.
Selina
So if we if we uphold if, say, Miranda, the health director upholds that denial, your next step would be to appeal it to the health committee.
Andy
Okay.
Selina
Which that I don’t believe that happens very often. We don’t really deny. I mean, a lot of things get denied and we kind of had to rework our process. And so we’re trying to reduce the number of denials by education and by letting people know this is what you need to do. If you’re not sure, reach out and ask, because, you know, we don’t want you to get stuck with, you know, sometimes, you know, $50,000 bill for something or a $10,000 bill. That’s a lot of money. And most of us cannot afford that.
Andy
Yeah. That’s a, that’s a lot.
Selina
It is, it is. And I, you know, and I’ve seen that happen. And, you know, I myself will explain to people, this is what you need to do. And, you know, and sometimes, you know, vendors, the providers offices, because we send a copy of the denial letter to the patient and to the provider’s office, and a lot of times the provider’s office will try to reach out to the patient. And if they don’t get any response from the patient, then they’ll reach out to us like, look, we got this, we got this approved, something approved. But we have everything that we send out says, you have to call in each visit. So, you know, and it’s a never it’s, it’s a never-ending process of kind of being fluid and changing and trying to find the right balance.
Andy
So let’s say I have nine, you know, physical therapy appointments lined up, and I’ve set them all because the physical therapists are booked out typically. Right. Can I give you all the dates and times?
Selina
Yes.
Andy
And get authorizations for those?
Selina
Up to six.
Andy
Okay.
Selina
So like right now we auto approve six visits for physical therapy.
Andy
Annually or in a lifetime?
Selina
Annually.
Andy
Okay.
Selina
Yes. And that, you know, and if after the first six then if the physical therapist thinks that you need more, they can submit a treatment plan request to the medical review panel which formerly gatekeeping requesting more visits.
Andy
Okay. So, do you have any like insider tips on how to use PRC? Any tricks of the trade tricks?
Selina
The, you know, it’s not so much tricks as just be proactive. If you’ve received denials before and you know why, let’s prevent that. Call in when you leave your doctor’s office and you have a scheduled appointment for another month out, don’t wait.
Andy
Right?
Selina
I mean, if you need to call from call on, call from your car and let us know that, hey, this is what my doctor’s office did, or my provider wants us to do this. I went to the orthopedics. They want me to do an MRI. We’ll need those notes so we can get that approved. So, there’s different things. But if you let us know. And if we have access to, if we’ve received the notes, if we can get those notes, we can get things moving quicker. We just need to know that that’s what they want.
Andy
So I’ve left the orthopedics office. I need an MRI. They want me to get that done as soon as possible.
Selina
Right.
Andy
I give you a call immediately. What’s the turnaround?
Selina
It depends on how fast we can get the notes. Okay. The like, you know, we, OHSU Samaritan are pretty easy to get chart notes from because a lot of us have access to be able to go in and pull those chart notes if we need to. Some of the other ones aren’t so easy. And sometimes it takes a phone call. We’d like to be able to turn it around in a week, if at most, you know, sometimes two. It depends on how urgent and stat like, say, you’ve ripped every ligament in your knee. Well, that’s pretty stat because you can’t walk. Or, broke your arm. You know, we’re not going to say nope. Nope. Sorry.
Andy
Can’t go.
Selina
Yeah. If you do that and you go to the emergency room, you are going to get an automatic orthopedic, referral. That’s automatic. We will. Call us, get your number, but we’ll need their treatment plan. So, treatment plans are a big one. I guess too. So, if we send you out in a lot of the letters that our patients get from us. As far as the medical review panel is approve orthopedic evaluation, need a treatment plan, that doesn’t mean we go and then we’re just going to do all of it.
Andy
Right.
Selina
They need to send us a treatment plan to see what you know, what needs to be done. So, we can, you know, we look at that.
Andy
Allocate the funds for it.
Selina
Yes. Yes.
Andy
Okay.
Selina
Yes.
Andy
All right. So, let’s leave PRC for a minute. Let’s talk about the Pequot cards. Does every tribal member have one? What are they?
Selina
The Pequot card is a pharmacy benefit. Through the Pequot tribe CVS Caremark. Which is $500 per year, which would be used more for like, say, it’s a medication that you can’t receive from your primary clinic, whether it be your IHS clinic or what have you. But you have to go get it from Walmart
Andy
It’s 80 bucks.
Selina
Huh? It’s 80 bucks. Yes. And so, you can if your Pequot card can cover that.
Andy
Up to $500.
Selina
To $500 per year. Yes. And I know that there’s been some, I think some misunderstandings on that. Well, where they’ve used maybe they’re $500 here and the pharmacy’s just taking it out, but then, then they keep going and then they’re sending receipts in for reimbursement, but they can’t be reimbursed because they’ve already it’s five straight $500. Whether you get you have to pay out of pocket and get reimbursed for it or the whole thing comes out of your Pequot card.
Andy
So.
Selina
Does that make sense?
Andy
Let’s clarify. Okay. Okay. So we have the Pequot, and the pharmacy, let’s say they don’t know what to do with that number. So I just pay the $80 to the Walmart there.
Andy
Right.
Andy
And then I can send you the receipt?
Selina
You can send me the receipt.
Andy
And it’s deducted from my Pequot balance.
Selina
What happens with that is that you can get reimbursed and so what I would need from your from you would not the cash register receipt, but the receipt that kind of looks like the medication on the label on the on your medicine.
Andy
Okay.
Selina
So it has your doctor’s name, the name of the medication and it’ll tell you, you know, kind of down towards the bottom, I think in the right how much it was. And then you submit that to me, then I email it out to Pequot and they will they send you a check.
Andy
Okay.
Selina
And I have those forms available. I can pre-fill them for you and send them to you. That that would be something that the patient, and I do have patients that like to do that themselves.
Andy
Okay.
Selina
And that will be deducted from their Pequot amount?
Andy
Okay.
Selina
I can also go in and look, if you call me and say, hey, I’m not sure. Have I, how much of my son’s have I used? I can go in and look and say, you’ve used this much already, so this is what you have left.
Andy
Okay.
Selina
And if you’re not sure, definitely give me a call.
Andy
Okay. Is that form on the website anywhere?
Selina
I believe so, if not, I will make sure it’s on there. Pequot-Reimbursement-Form.pdf
Andy
Okay.
Selina
Because I know on the on the back side of the form is the email address and the mailing address. The part of it is, is what you need. Those the information that you need on that form. And I’m not sure if everybody is aware of that. I can and I think that that is very good question because I’m not sure. So what I can do is I can do like a generic prefilled form, you know, using a test patient. And we can maybe put that out. So, this is the information you’re going to need, you know, and this is what we this is what needs to go to Pequot.
Andy
Does every tribal member have a Pequot number that’s unique to them?
Selina
Yes.
Andy
Okay.
Selina
Yes they do. And if you don’t have one then reach out or you’ve lost your Pequot card, reach out to me. I’m the one that generally does that, and I can get you a new one ordered. And in the interim, I can give you the information that you would need.
Andy
All right. So, I recently got my heart card in the mail. It did have my Pequot number on it.
Selina
Yes.
Andy
Can you tell me what the difference is between my heart card and my Pequot card.
Selina
So the heart card is more has a lot more information on it for you to give to. Your, a medical provider and it gives them the information on where to bill, what to bill with or what to send. That’s the difference. It’s not. It’s it does not negate calling PRC for an authorization.
Andy
Okay. But it’s for more it’s more accurate billing.
Selina
Yes.
Andy
For your PRC.
Selina
Absolutely.
Andy
Okay.
Selina
Yes.
Andy
Okay.
Selina
I’m hoping that helps.
Andy
No, it did help me.
Selina
Yes.
Andy
Because I got it in the mail, and I was I saw it, you know, it was in the newspaper we published that the newspaper, it was on the website, and then I was like, but what is what is it?
Selina
Yeah, yeah. And that’s a lot. You know, I believe there’s that that really sums it up though, is it’s got the information on it. It’s got your name on it, it doesn’t have your actual medical record number, but has the person number on it, which is how we identify you in PRC, in our, and how we pay and obligate our funds to you. And it has our billing address on it, and also, I believe, has the phone numbers on it to call.
Andy
Okay. And it has your Pequot because I remember seeing it.
Selina
Yes. Yeah.
Andy
And being like, do I need the Pequot card still then?
Selina
And but you know, but if you don’t have the, you know, I mean and we can order we can order the Pequot cards for you and we actually can redo the heart card in office if you’ve lost it or. Yeah. So that’s kind of nice.
Andy
So how do I utilize the resources of those cards.
Selina
So the heart card is kind of be like you can kind of use that like a secondary insurance. So, like say you and I, we both work for the tribe. So, we’re going to go see the dermatologist or something. So, we’ll take our HMA card and then with the heart card as well. And if somebody is going to ask well what is this. Well this is our, this is my secondary, this is my and here’s my authorization number. This is where you need to send my secondary claim to my claim with my explanation of benefits, so we can get that covered. Pequot, it’s a little different. You just if you have one and you haven’t used it, you should be able to just take it to your local pharmacy and they should be able to, with the information on that card, should be able to bill it.
Andy
Okay.
Selina
If there’s an issue then I, I’m always available, during work hours, sometimes after.
Andy
It’s like 24/7.
Selina
Pretty much sometimes it feels that way. You know, it does. Sometimes it does kind of feel that way. But, you know, it’s if I can help and you know how to get me, then I have a lot of people that do that. You know, if I know that information, I can give it to you. And sometimes I have the basic information. I keep a copy of the basic information with me all the time. What I may not know is your whole ID number, because that is related to your chart, your medical chart. And so I don’t have all of those memorized.
Andy
Right?
Selina
Some, but not all.
Andy
I feel like it would be impossible.
Selina
You’d be surprised at how many I can remember.
Andy
So you’re like the checker at the at like the store that knows all the produce codes.
Selina
Sometimes, yeah, yeah. You know, but after, you know, working for the, you know, and being in the health department for so many years, a lot of the numbers just
Andy
Stay.
Selina
They stay.
Andy
Yeah.
Selina
And it’s hard to get them out of your head sometimes. Okay. The one thing with the heart card I should mention is right now, we have not sent that to our out of area patients yet. We want to get this all fine tuned in for our 11 county service area first and see if there’s any changes. You know, kind of, you know, what do we need to do? Is there separate information that we need to put on for out-of-area patients? Because their things are different out of areas, it’s whole different beast.
Andy
So let’s talk about some out of area then. We’ve brought it up a couple times. What is out of area?
Selina
Out of area is our tribal members that live outside of our 11 counties service area. So we do service 11 counties here in Oregon. And please don’t ask me all 11 right off the top of my head because I probably don’t remember them all. But if you like, say, live in Alaska, Washington, Eastern Oregon, California, we do have an out of area benefit. So every year you have to call us though. And so your medical dental benefit is $2,000 combined. And we definitely recommend if you have a primary insurance definitely use that. That will make that money go a lot further. Apply for whatever’s available in your state. If you might qualify for whatever that state’s Medicaid plan is or if you have a private work insurance, definitely utilize those that will make that go further.
Andy
Okay.
Selina
So that’s medical dental. Vision is we kind of treat the vision the same as we do the PRC in area. But it’s a different dollar amount. So if you are 55 and older, you get that $450 every year, which that covers an exam and hardware. And I do recommend if you are near any sort of IHS facility, go get your eye exam done there and then because that’ll be done at no, no expense. So then you can utilize that whole benefit. For,
Andy
For glasses.
Selina
For glasses or contacts. So that’s yearly for elders 55 and older, students full time and for diabetic.
Andy
Okay.
Selina
So for the rest, everybody else it’s 450 every two years.
Andy
Okay.
Selina
We also have a $2,000 cataract benefit. Aside from the $2,000 medical and dental. So if you, you know, and cataracts, depending on where you’re doing it, if you’re using and mostly that’s mostly a Medicare age thing. But we can pick up pick up that and it might be that the co-pay for that, for that might work. If it’s under the 2000, then, you know, we can but you know, might be able to split it. Yeah. And for both eyes, there’s also a $2,000 a year hearing aid benefit. Not an annual benefit, but a $2,000 hearing aid benefit, which is every 3 to 5 years.
Andy
For?
Selina
For hearing aids.
Andy
For everybody?
Selina
For everybody if they need them. We here in the 11 counties utilize Costco. And that makes that go a lot further. Whereas like if you go somewhere else, it might be $4,000 for hearing aids where Costco, you can go and get a set of you can get two and a your chargers for them or whatever for under two for right about $2,000.
Andy
Alright.
Selina
So that makes that benefit go further. Yes.
Andy
Okay.
Selina
And they also get the same out of area Pequot benefit. It’s the exact same.
Andy
So you had talked about a $2,000 combined for medical and dental. So what if I go to the dentist I’m out of area. I go to the dentist and it’s, $1,200, but I don’t use any of the medical. Is it a pot, or?
Selina
It’s just one pot.
Selina
It’s we’ll pay the 1200. But that will take out of that. Yeah. So that leaves you with the $800 left for the medical.
Andy
Okay.
Selina
Or dental? It’s one pot combined.
Andy
Okay. Just felt like a good question to ask.
Selina
Well, it used to be that you had to you when you called in, you had to call in quarterly, and you had to pick and choose which one. Well, the, the then you have to wait till the next quarter to change it. And we’ve changed that. So, you can call in January, first, 2nd March, whatever and use that $2,000. You don’t have to tell us what it’s for. You just want to use the $2,000 medical dental one.
Andy
Right.
Selina
And so whether you go to the dentist or you go to medical, it all comes out of that same $2,000. And when it’s gone, it’s gone.
Andy
Okay. Yeah, I remember using that when I lived out of area and it was specifically for vision because OHP doesn’t cover vision.
Selina
No.
Andy
And so I needed glasses or contacts. And I remember it was one pot and I would just order the entire years’ worth.
Selina
Yes. And we’ve had people do that, especially if they go to like an IHS facility, which is really nice. You know, you go get your eye exam done and you want to get or you could order your whole years’ worth of contact lenses at that time.
Andy
Yeah.
Selina
And know that you’re good to go.
Andy
Yeah. Yeah.
Selina
Which helps. And I do encourage that. I really try to encourage our tribal members who live near any IHS facility, if you can utilize it. Because that will make your IHS dollars, your PRC dollars go further. That out of area benefit will go further if you utilize the nearest IHS facility. Yeah. You know, in in Eugene there is the Coquille clinic. They are there’s still services that I don’t think they have quite yet, but we do have a few people that utilize that. We have tribal members that live like out in Pendleton, that area that use Yellow Hawk, and that is a good facility. Grand Ronde and Chemawa of course, are the standards locally. But yeah, if any, any way to make that money for you, go further. Absolutely. Do it. Yeah.
Andy
It’s like couponing.
Selina
I haven’t couponed in years.
Andy
That’s a humble brag.
Selina
It is, it is.
Andy
Okay, so, let’s cover anything that you think we might have missed that you think we need to talk about what?
Selina
Gosh.
Andy
What do you think is, is just vital for your listeners, for your membership right now?
Selina
Okay. So right now, and this is kind of a new thing. And I’m probably going to stumble over this one. And this has to deal with unpaid medical bills. And being sent to collections. So I’m kind of just going to read what the where this comes from and not read the whole thing. But it comes from the Consumer Financial Protection Bureau and Indian Health Service. So in this and we are trying to send this, also give this to providers as, if requested.
Andy
So these aren’t your words this is coming.
Selina
No. This is coming from this is coming from way up high okay. So, the you know the bottom line basically what this is, is a patient who receives contract health care services, PRC services that are authorized by PRC, Indian health services, shall not be liable for the payment of any charges or costs associated with the provisions of such services. So under this provision, approved PRC care should have no out-of-pocket expense for the patient. That, and with the caveat that you’ve called in, you’ve done your part. So yeah, this is something I’m still learning about, to be honest. And as I can get out more information, we will try to get this out on the web page and in the paper soon as I can kind of consolidated into, I think, something that’s more manageable instead of six pages.
Andy
Right. And something that we understand.
Selina
Yeah.
Andy
Because I don’t, I don’t know what other people feel, but sometimes I’m like, that’s jargon. Can you like,
Selina
Yeah.
Andy
Can you say it to me like you’re talking to your niece?
Selina
Yes. Yeah. So, like so like this section right here is the current guidance. Patients are not liable for any costs or charges associated with the services authorized under a PRC referral. With the caveat, though, that you have done your part, received your authorization. That includes copays and deductibles. Providers are prohibited from collecting any payments for these services from the patient, whether directly or through referral to an agent for collection. So that’s huge. That is a huge thing. And I think that this, this will benefit a lot of, a lot of tribal people, not just our own within our 11 counties, but even the ones outside, if they’ve been sent from like, say, Yellow Hawk or, you know, the ones in Oklahoma or the ones in California, they’ve referred out, you know, so hopefully this will be hopefully this will be a, you know, a good thing. And I’m hoping to learn more about it. So, I understand it better.
Andy
Okay. So.
Selina
I’m still learning.
Andy
If I get a referral I’ve gotten my authorization number. And then everything seems to go fine. But I get contacted that, this bill is due or it’s going to go into collections.
Selina
First thing is, is did they say it’s this secondary? Did they bill PRC first for it? If they have not billed PRC, then they need to make sure they bill us. If they don’t bill us and they send you to collections, then you know, we, we don’t deal with the collection agencies. That is something we cannot do. But we can call the facility and say, hey, guess what? You know, you cannot send them to collections. You did not bill us in the timely manner we’ve requested you do this or the patient has requested. And that’s happened where patients have said, hey, you need to bill these guys. And they’ve assumed that a billing place has billed us and they didn’t. And so they’ve gone to collections, I mean, and and I’ve had it happen to myself. I know and it’s it’s terrible and I completely get it. And sometimes it’s just out of our hands where if we can’t get that information in there, when we’ve put it out there numerous times, I mean, we send requests for information, we call for information, you know, letters, phone calls, faxes, it. Sometimes it’s frustrating at times.
Andy
Okay.
Selina
But I’m hoping I’m hopeful that this will be something that can help protect our tribal members from getting sent to collections.
Andy
What if it’s something where PRC was billed many times and they didn’t get paid?
Selina
It could be because maybe we have the bill, but we don’t have all the information from that provider. It could be we didn’t have. We’ve requested a W9 multiple times. We’ve requested maybe an explanation of benefits. We maybe we needed chart notes for to. So those are some reasons why things don’t get paid. And we send out multiple requests. And it’s you know, we do the best that we can. And it’s hard when we can’t get that information. You know, in some places. Well, we can’t give you that. Yeah, you can. I’m very upfront. It’s like, no, we I’ve given you this information. I’ve requested this information. Now, this is on you,
Andy
Okay.
Selina
This patient is not, I am very adamant about not having our patients punished for a provider’s office or billing offices. Lack of doing their job.
Andy
Okay.
Selina
I will fight for you for that.
Andy
Okay. All right. So, I think that wraps up our podcast. So, I just have one final question for you. This is the question we have to ask all of our newcomers.
Selina
Oh God.
Andy
What is your favorite tribal event?
Selina
Oh my gosh. I don’t have just one. Of course, our summer powwow is probably my favorite, one of my favorites. It’s a lot of getting to see people I don’t see all the time, and visiting with people that I don’t get to see all the time. But when families and in my family, we always have like a gathering at one of my cousin’s house and people, they come from all over. And then that’s my one of my favorites. My other favorite is probably restoration. Again, getting to see people you don’t see all the time. And I love it because a lot of people I’ve, you know, I’ve made lots of friends and contacts over the last almost 28 years that I’ve lived here. And a lot through the 25 years I’ve worked for the tribe, I’ve made some very good friends and so sometimes I only get to see those people, though, during different events. And so those are my favorites
Andy
Those two,
Selina
Those two.
Andy
So like powwows?
Selina
I love pow wows. I’ll go to Grand Ronde. I see people up there that maybe don’t come to ours, but that I know that will come from. Yeah, I do, let’s see, what else do I like? There’s just most I do.
Andy
You just like the gathering.
Selina
I do, I do, I do like the gathering aspect, the, like.
Andy
So if the same people who show up at, culture camp. That would be your favorite one.
Selina
Yeah, I do, I yeah, you know, and my kids are all older now, so they don’t really, you know, culture camp is not their thing anymore. But when my kids were little. Yeah, taking them to culture camp was a lot of fun. You know, I think that’s where I learned how to sew moccasins. And I made my son’s first pair when he was about eight, nine months old, so. And I still have those.
Andy
Nice. Yeah.
Selina
So I mean, I do I like the gathering. I like the, the friendships and stuff, you know, and restoration powwow besides even the powwow but just the luncheon part of it where you get to talk and meet with people, I think was last year I attended my very first Elders Honor Day. Yes.
Andy
Was it just the first one you attended or are you a baby elder?
Selina
I am a baby elder.
Andy
Oh my gosh.
Selina
I guess I, yes, I am.
Andy
Round of applause.
Selina
No, I prefer elder in training. Thank you. But yeah, but, you know, it was nice because when I went to my first one, I met a lot of different people that I had never met before. And and it was fun.
Andy
So are you going this year, then? It’s coming up.
Selina
I don’t know if I’m going to be able to make it this year. I’ve just got a lot on my plate as far as I have a 12-year-old that plays softball.
Andy
On her travel team
Selina
A travel team and S.E.T. So, I am going to be busy.
Andy
An over exceeder.
Selina
I’m not. I’m just glad she does it. You know, I mean, that’s another one. I, I do love watching my, you know, my kids play sports. I always have. And I’ve always been their biggest fan, their biggest cheerleader, whether they liked it or not.
Andy
Yeah.
Selina
So I, you know, and I’d just like to end too by saying, you know, if anybody has any other questions that I may have missed or that I did not touch on, please feel free to reach out to me, to my office. My direct number is (541) 444-9648. My email is Selina
r@ctsi.nsn.us
Andy
Awesome. Yeah. So, if you have any questions and you want clarification, just reach out because our, our staff is here to help you. Don’t, don’t use the unaffiliated Facebook.
Selina
Oh God no please don’t. No because that’s not accurate.
Andy
Contact us directly. Go to the website, find your information from the source.
Selina
Yes. And what I will have somebody, we’ll look at the website and see what information we need to add on to it. And if we need to add on this Fair Collections Act thing, I think we should. And I can also include a copy. We’ll get a copy of the Pequot form and maybe a test one, of what needs to be filled out so you’ll have a blank one and one.
Andy
Okay. Like an example.
Selina
An example one on there and then one to download.
Andy
Awesome. So, example name example last name. Example number. Awesome.
Selina
Yes. And then I also make clarification with Pequot itself. If the patient does not know exactly what their ID number is, if they can still process it without that.
Andy
Okay. All right. Well thank you so much for coming to our show. Thank you for letting our listeners know and our members know. And, I really appreciate this time. You’ve dedicated.
Selina
Well, I was glad to do it. I just hope it wasn’t too much of an information dump all at once. And, feel free to take time to process the information and definitely reach out if you have questions.
Andy
All right. You have a great day.
Selina
Thank you. Andy