Purchased Referred Care

Referral Process and Patient Responsibilities

3rd Party Benefits Brochure

Patient Benefits Breakdown

PATIENT ASSISTANCE

We assist eligible Native American patients with payments for approved medical and dental services. When patients need medical services that are not provided at Lake County Tribal Health, we will refer to an outside provider and assist with the payment of these services for our PRC eligible patients.

ELIGIBILITY FOR PURCHASED REFERRED CARE SERVICE

1. Patient must provide Indian eligibility:

a. Member of federally recognized California tribe

b. Any Indian who holds trust interests in public domain, national forest, or Indian reservation allotments in California

c. Any Indian in California who is listed on the plans for distribution of assets of California Rancherias and reservations under the Rancheria Act of August 18, 1958, and any descendent of such an Indian.

d. Non-Indian women pregnant with an eligible Indian’s child who resides within Lake County is eligible for PRC during pregnancy through post-partum (6 weeks).

e. Minor children living in an Indian household (natural or adopted child, step-child, foster-child, legal ward, or orphan of an eligible Indian).

f. Members of Federally recognized Tribes from out of state must submit proof of close Social and Economic ties to a California Native American from one of the six local tribes.

• Marriage
• Children
• Employed by local tribe (not casino)
• Tribal resolution, approved by the Lake County Tribal Health Consortium Board of Directors

2. Must be a registered patient of Lake County Tribal Health.

3. Patient must live within Lake County Tribal Health’s Service Area (Lake County).

HOW TO USE THE PURCHASED REFERRED CARE PROGRAM

Services must fall within Lake County Tribal Health’s currently approved Levels of Care in order for LCTH to consider payment.

LCTH’s PRC Program currently funds Category A-Priority 1 & 2, Category B-Priority 1 & 2, Category C-Priority 1 & 2, Category D-Priority 1.

1. Patient must have a current referral from Lake County Tribal Health. However, a referral is not an obligation to pay.

a. Patients must renew their referral at least every 6 months for a specific number of visits. It is the responsibility of the patient to ensure that the referral is current.

b. Lake County Tribal Health must be advised if the physician to whom the patient was referred to is going to refer the patient to another physician or healthcare facility.

2. Lake County Tribal Health Purchased Referred Care Program is the payor of last resort and all available alternate resources must be utilized first.

a. Patients must apply for all available alternate resources (i.e., Medicare, Medi-Cal or other available programs) and obtain the alternate resource or a valid Medi-Cal denial letter before they may become PRC eligible.

b. Valid Medi-Cal denial reasons include: being over resources and being over income. Non-valid denial reasons are: missing appointment, not turning in required documentation. A copy of the valid denial letter must be submitted and will be valid for a year.

c. Pending provider availability, all patients will be referred to providers that accept the patient’s insurance. If the patient chooses to see a provider who does not accept his/her insurance, PRC will deny payment of services.

3. Emergency room visits - In emergency cases, the PRC staff will take the appropriate steps when patients notify them of Emergency Room care. It is highly encouraged that patients notify the PRC staff of Emergency Room care so that the PRC department can determine the need for insurance enrollment, request follow-up care from the patient’s PCP, identify a potential CHEF case, or facilitate other needs arising from said emergency (i.e., payment of prescriptions, DME, additional referrals, etc.)

The patient, an individual or agency acting on behalf of the patient, or the medical care provider, is highly encouraged, within 72 hours after the beginning of treatment for the condition or after the patient’s admission to a health care facility, to notify PRC of receipt of the services and provide information to determine the patient’s relative medical need for the services. If the patient is elderly or disabled, they are highly encouraged to notify PRC at least within 30 days (P.L. 94-437). An elderly Indian means an Indian who is 55 years of age or older

4. It is the patient’s responsibility to submit insurance information to the provider of services.

5. It is the patient’s responsibility to submit bills to the PRC department upon receiving them. Any bills submitted to the PRC department that are over a year old from the date of service may be denied.

6. It is the patient’s responsibility to provide the PRC department with a current address and phone number in case PRC has to contact the patient regarding their eligibility.