Purchased Referred Care

Referral Process and Patient Responsibilities

Proceso de Referencias Médicas a Especialistas y Responsabilidades del Paciente

3rd Party Benefits Brochure

Patient Benefits Breakdown

PATIENT ASSISTANCE

We assist eligible Indian clients 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 patients.

ELIGIBILITY FOR PURCHASED REFERRED CARE SERVICE

1. Patient must provide Indian Verification:

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 up to a Level III.
Details on the levels of care can be downloaded here (brochure pdf).

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 an alternate resource (i.e., Medi-Cal) 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 must be reported to PRC within 72 hours after the services are rendered to be eligible for PRC coverage. Any ER visit will be reviewed and prioritized for payment by the PRC staff, which means that the patient must have an alternate resource or a valid Medi-Cal denial (Federal Regulation). Elders & disabled patients (55 and above) are allowed 30 days to notify the PRC Staff of an ER visit.

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.