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  • PRC receives limited funding from Congress to pay for specialty care that is not available onsite at IHC for patients meeting the eligibility requirements.

  • It is not an insurance or entitlement program.

  • It remains the payer of last resort.

  • Covered services are those that meet the Medical Priority and are generally only emergency services or those necessary to prevent the immediate threat to life, limb or senses. 

  • It does not cover chronic conditions or repetitive treatments.

  • There are 6 eligibility steps listed under the Code of Federal Regulations that must be met before PRC funds can be approved to pay for specialty services:

    1. Eligible Indian

    2. Proof of Residency

    3. Meets the Medical Priority

    4. 72-hour notification or Prior Authorization given by IHC

    5. Completed Screening and Applied for Alternate Resources 

    6. Service is not available onsite by Indian Health Council


​PRC is considered the “payer of last resort.” The use of alternate resources is required when such resources are available and accessible to the individual, such as:

  • Medicare A and B 

  • State Medicaid (Medi-cal) 

  • Private Insurance

  • Workman’s Comp

  • Covered California

Patients must complete the screening process with one of IHC’s Eligibility Case Managers before a referral can be approved. PRC will not pay until all other resources have paid.


Question: My provider ordered me a referral, when can I schedule my specialty appointment?

Answer: You will be notified by the IHC Referral Team when you are approved to schedule your specialty appointment. If you are requesting that PRC cover all or a portion of the expenses of the referral, you must complete all 6 of the eligibility steps before you can schedule your appointment. 


Question: What does my initial specialty referral cover? 

Answer: The initial referral covers a consultation. Any recommendations for treatment made by the provider needs to be brought back to IHC for approval. PRC will not pay for services that have not been approved or referred for by the specialist.


Question: What is the screening process and why do I have to complete it? 

Answer: The screening process is required per the Code of Federal Regulations. Patients must meet with one of IHC’s Eligibility Case Managers to be screened for alternate resources (Medi-cal, Medicare, Private Insurance, Worker’s Comp, Covered California). Be prepared to provide proof of income and current residency documentation.  


Question: Why is my treatment being denied by PRC? 

Answer: Treatment is denied when a patient is eligible for an alternate resource or the treatment does not meet one of the Medical Priority Levels. 


Referral Team (contact for referral related questions):

• Janie Ogilvie - (760) 749-1410 x5366 or Tricia Navarro (760) 749-1410 x5269


Eligibility Case Managers (contact to be screened and apply for alternate resources): 

• Della Freeman - (760) 749-1410 x5297 or Dawn Roberts (760) 749-1410 x5285


Purchase Referred Care Officer (contact for payment related questions or to provide 72-hour in-patient notification):

• Leanne Aguilar - (760) 749-1410 x5230

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