PRC Program
We are delighted to announce a significant and exciting development in our tribe’s healthcare journey: following the recent funding allocation from the Indian Health Service (IHS), the UKB has officially launched the Purchased and Referred Care (PRC) program, commonly known as Contract Health Services, as of January 1, 2025. This momentous occasion marks the beginning of a new era in which we can offer tailored, responsive, and culturally attuned health services to you, our cherished tribal members. The launch of the PRC program is not only a testament to our tribe's resilience and commitment to health but also a promise of improved accessibility and quality in healthcare delivery. We are truly excited about the positive changes this will bring to our community and happy to present you with the following information regarding the new program.
Under the Indian Self-Determination Education Assistance Act (ISDEAA), PRC is a medical referral program for specialty care services that are not available in an IHS or tribally operated program. It is important to know that all UKB members will continue to be eligible for direct patient care services at any IHS or Cherokee Nation Health Services facility, as well as any other tribally operated health facility that services all tribes under ISDEAA. The new PRC program at UKB will be utilized when a provider from an IHS or tribally operated health facility refers an eligible patient for specialty care or for other necessary medical services not offered or otherwise accessible. The following guidance is provided, which is standard PRC program protocols:
Information for referring providers:
Point of Contact: Caleen Bolin
Phone: 918-871-2833
Fax: 918-414-4006
Email: ukbprc@ukb-nsn.gov
Location: UKB Wellness Center on the UKB campus
Purchase Referred Care Services exclusive for UKB members
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Inpatient Hospital Stay & Physician Charges
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Outpatient services, Physician Fees & Medical Specialist Fees
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Dental Services – advanced or oral surgery
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Medical and Surgical Supplies
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Optometry Services
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Patient Travel Reimburses (Priority I Care Only)
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Medical Emergencies
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Pharmacy Services
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Dental Services
How the PRC Program will function:
Funded by the Indian Health Service (IHS) the Purchased / Referred Care Services (PRC) Program is for medical/dental care provided away from the United Keetoowah Band Health Clinic, or other tribal health care facility. PRC is neither an entitlement program nor insurance plan and is to be considered the payer of last resort.
● Purchased and Referred Care (PRC) includes resources for the provision of medical services outside the scope of the direct care program.
● Due to limitations of PRC resources, funds must be managed in accordance with established medical priorities.
● PRC resources are used for referred services, "referrals," and emergency services.
Eligibility
To be eligible for the PRC program, you must meet the requirements listed below:
1. Eligibility is limited to exclusive UKB tribal members only, and
2. Must reside on a permanent basis within the UKB PRC Service Delivery Area, which includes the following counties: Adair, Cherokee, Craig, Delaware, Nowata, Rogers, Sequoyah, and Washington Counties, and the portions of Mayes, McIntosh, Muskogee, Ottawa, Tulsa, and Wagoner Counties in Oklahoma that are within the geographic boundaries of the UKB’s Tribal Districts.
The following individuals are also eligible:
● Exclusive UKB member that is a full-time boarding school, college, vocational, or other academic students who are temporarily living away from the Service Delivery Area specifically for the purpose of education.
● Exclusive UKB member who is temporarily away from the service Delivery Area due to travel, employment, etc.
● Exclusive UKB children placed in foster care away from the service Delivery Area by order of a court of competent authority and who were eligible for PRC at the time of the court order shall continue to be eligible.
● A non-Indian pregnant woman carrying the child of an exclusive UKB member is eligible for PRC care during pregnancy and for 6 weeks postpartum for OB-related care.
● Non-Indian adopted children, stepchildren, and foster children of an otherwise eligible exclusive UKB parent.
Referrals
Referrals are written and submitted to the UKC PRC program by IHS or tribally operated facility providers for services deemed medically necessary but not offered or otherwise accessible within the direct care service unit/facility. However, a referral does not constitute authorization for payment. All referrals must be reviewed by the PRC team to verify eligibility, preauthorization as applicable, and alternate resource requirements (explained below) of the PRC program. A member of our PRC team will contact you upon receipt of the referral to either schedule an in-person visit to obtain documentation or to provide guidance on the secure electronic submission.
Payment for medical care outside an IHS or Tribally ISDEAA-operated facility can only be authorized by a UKB PRC official while funds are available.
Alternate Resources
PRC is the payer of last resort. Therefore, you must apply for funding with all available resources to you, such as private health insurance, Medicare, Medicaid, workers compensation, vocational rehabilitation, auto insurance, and other personal injury or liability insurance. Use of alternate resources helps to maximize and extend the PRC funding. UKB will also provide benefits coordinator functions to assist you in navigating alternate resources and applications for Medicaid or other alternate resources.
Emergency Services
You must contact the PRC department within 72 hours of receiving emergency care at a non-Indian Health Service facility. For an elderly or disabled person receiving emergency care, this may be extended to 30 days. If a patient is unable to contact PRC, a person acting on their behalf must contact PRC within the same time limits. All non-emergency care must be pre-authorized by PRC before receiving medical treatment, or you may be responsible for all charges incurred.
Appointments
It is important that all referral appointments are kept. If you need to cancel an appointment, you are asked to give at least three days’ notice by calling the PRC office. Any changes to the appointment must be made by the PRC staff to ensure PRC authorization. The patient may, however, elect to reschedule such services with no involvement of PRC and assume financial responsibility for payment of those services. Patients are to take alternate resource identification with them to their appointment to ensure providers have accurate and appropriate billing information.
Follow-Up Appointments
For additional appointments, testing, or other services, a new referral may be required by your primary provider. You must call the PRC office to verify your need for additional referrals prior to any further appointments. Failure to follow this step could leave you responsible for any charges accrued.
Claims Coordination
Patients are to provide the PRC office with copies of the following documents for claim processing:
● Itemized bills received
● Alternate resource payment information
● Explanation of Benefits, Report Remittance Statements/Reports, or other documentation of payments
● Responses to applications for alternate resources
● Collection notices
● Medical Records
Denials
If your request for PRC funding is denied, you will receive a letter informing you of the denial. Sometimes all that is needed is more information. If you already went to a non-Indian health service provider, a letter of denial for payment will also be sent to them. You may appeal the denial and request reconsideration of payment in writing within 30 days. A copy of your denial letter should be sent to the PRC listed at the bottom of the denial letter.
In closing, the establishment of our own PRC program is a beacon of progress and hope, promising to bring transformative good to our tribe. As we embark on this impactful journey, we are eager to witness the positive changes and improved health outcomes it will usher in for all UKB members. Should you have any questions or concerns as we work diligently to roll out the program and address any gaps that arise, please do not hesitate to contact our new PRC office. We are here to support you every step of the way and are enthusiastic about the bright, healthy future ahead.
