• What is considered an emergency?

  • The effects of time on the patient’s medical condition or if the patient’s condition requires immediate attention to prevent the loss of life or a limb. 

 

• What is “alternate resources?”

Alternate resources refer to health care options outside of the IHS, encompassing various providers, institutions, and programs for health service payments, including Medicare, Medicaid, State Children’s Health Insurance Program, local health initiatives, and private insurance.  Examples of alternate resources include:

• Medicare

• Medicaid

• Veterans Benefits (Champus, Champva)

• Private Insurance (such as Blue Cross Blue Shield, Cigna, etc.)

• Auto Insurance (liability)

• Workman’s Compensation

• State Maternal and Child Health Programs

 

• Do I have to apply for Alternate Resources?

  • Yes, this is required by 42 C.F.R. 136.61, Payor of last resort.  Approval of PRC payment for services is considered after all other Alternate Resources (AR) are applied. Patients who are potentially eligible are required to apply for alternate resources. 

 

• Purchased Referred Care for HHC Patients with Insurance

PRC for an eligible HHC patients who meet eligibility requirements and have Medicare or private insurance. 

1. Visit with PRC for any demographic or insurance updates.  For new patients, please speak with a PRC Specialist for the referral process.

2. Notify PRC at least 72 hours before the appointment date so your active referral can be updated or in case you need to schedule with your primary care provider for a new referral. 

3. Inform the medical specialist/health facility at the time of registration that HHC PRC is a secondary payer/payor of last resort.

4. If you receive a bill from a provider, please provide a copy to PRC (via email or drop-off in person).

 

• Purchased Referred Care for HHC Patients without Insurance

PRC for eligible HHC patients who meet eligibility requirements and who do not have insurance.

1. You must apply for all available resources, such as Medicaid, Medicare, and any Health Exchange.  HHC’s Patient Benefits Coordinator can assist you with the application process for alternate resources.  Failure to exhaust available or potentially available alternate resources may result in denial of payment. 

2. For new patient’s please schedule an appointment with PBC to determine whether you are eligible for alternate resources. 

3. You must utilize the services provided at HHC before being referred out. 

4. Referrals for outside services must be sent to PRC, services must be deemed medically necessary prior to a referral being generated.

5. Referral is sent to the requested facility for an appointment and patient will be notified

6. Patient will need to communicate with PRC of appointment date/time

7. If a bill is received from a provider, please provide a copy to PRC (if your referral has been approved)

   1. If your referral was denied, patient will be responsible for any costs