The Siletz Tribal Health Department, operated by the Confederated Tribes of Siletz Indians, partners with the Indian Health Services (IHS), a branch of the U.S. Department of Health and Human Services.
This program extends its services to all Siletz Tribal Members across an extensive 11-county area in Oregon. In cases where medical services are unavailable at the Siletz Clinic or other IHS facilities, individuals can utilize the Purchased/Referred Care (PRC) program.
Here’s a more detailed breakdown of the PRC program:
- PRC funding is determined annually by the United States Congress.
- Unlike entitlement or insurance programs, PRC doesn’t offer a predefined benefit package; it operates based on established guidelines and eligibility criteria.
- The availability of funds determines the level of care provided. Towards the end of the fiscal year, funding may be limited.
- PRC serves as a supplementary option and is known as the “Payer of Last Resort” which means that it will only pay for services when all other means of healthcare payment are exhausted. This prioritization of alternative resources ensures better healthcare provision for Siletz individuals.
- Only PRC staff members are able to provide authorization numbers
Services
The Purchased/Referred Care (PRC) program covers medical and dental services that tribal or IHS facilities can’t offer. PRC comes into play when:
- There’s no tribal or IHS facility within a 40-mile radius of where the patient lives.
An IHS or tribal facility can’t provide the emergency or specialized care needed. - The patient’s other financial resources aren’t sufficient to cover the full cost of the required care.
- The service falls within established medical priorities.
Eligibility Requirements
To qualify for Siletz Purchased/Referred Care (SPRC), you must meet one of these criteria:
- Enrolled Siletz Tribal Members: You must be an enrolled member of the Siletz Tribe and live permanently within the 11 county service area.
- Dependents under 19: If you’re under 19 and live with a PRC-eligible tribal member who is your legal guardian.
- Residency on Siletz Reservation/Trust Land: If you live on Siletz reservation or trust land and are a member of a federally recognized tribe.
There are Special Provisions that may grant Eligibility to those with close socio-economic ties who normally are not covered by PRC To learn more about these or to see if you qualify please contact a PRC Tech at 541-444-9677 or SiletzPRC@ctsi.nsn.us.
Utilization of Alternate Resources
It’s mandatory for individuals seeking healthcare to apply for and use all accessible alternative resources, including:
- Medicare A and B,
- State Medicaid or Oregon Health Plan (OHP),
- State or federal health programs,
- Private insurance,
- Siletz Tribal Health Clinic, and
- Other IHS, Tribal, or Urban health facilities.
As per 42 CFR 136.61, the Siletz PRC program is obligated to act as the Payer of Last Resort for eligible persons, regardless of any conflicting state or local laws.
PRC funds must not be used for services that are readily accessible and available within 40 miles of the individual’s residence at IHS facilities, Urban Indian Health Centers, or Tribal Facilities.
Patient’s Rights & Responsibilities
Registering: You need to sign up and update your info every year at the Siletz PRC office or the Siletz Community Health Clinic. This helps decide if you qualify for Direct Care Services and PRC services. You’ll need to prove your Indian heritage and residency.
Prior Approval: You must get approval beforehand for any non-emergency treatment that needs PRC funds.
72-Hour Notice: If you get emergency treatment at an ER or Urgent Care, or if you’re admitted to a non-IHS facility, tell a PRC staff member within 72 working hours. They watch closely how ER services are used. There’s a medical pro available 24/7 to help decide if you need urgent care. Call PRC or the Clinic to reach them.
Denial and Appeals: If PRC denies your payment, they’ll explain why in a letter. You can appeal in writing to the Health Director within 30 days. They’ll review and respond. If they still say no, you can appeal to the Siletz Tribal Health Committee within 30 days. If that’s a no, your last chance is to appeal to the Siletz Tribal Court
Common Denial Reasons:
- You didn’t tell PRC within 72 hours after an ER or urgent care visit.
- You didn’t prove your Indian heritage or you’re outside the service area.
- Your request for specialty care didn’t meet requirements.
- You didn’t get prior approval for non-emergency services.
- You didn’t use Alternate Resources.
- Medical review didn’t support using the ER.
Tips for Using PRC
- Call Early: As soon as you know your appointment date, call for an authorization number. For specialty care, it might take time for approval, so don’t wait.
- Notify Every Time: You need to tell PRC about each appointment and get a new authorization number each time. Even if someone else calls for you, make sure to get the number and keep a record.
- Keep Records: Write down your authorization numbers on your calendar next to your appointment details.
- Understand Insurance: If you have insurance, PRC can only pay after your insurance decides on the claim. You might get a statement explaining what’s paid and what’s still due. If you’re unsure, check with your provider.
- Update Info: You must update your info yearly or if anything changes, like your name, address, or insurance. You can do this by downloading a form, asking PRC to mail you one, or picking up a form from the Siletz Clinic’s front desk.
Contact Information
Address
PRC
200 Gwee-Shut Rd.
PO Box 320
Siletz, OR 97380
Telephone
541-444-9677
Fax: 541-444-9645