Purchase Referred Care
The Cowlitz Indian Tribe has the privilege and pleasure of managing the Purchase Referred Care (PRC) program (formerly referred to as CHS) on behalf of the federal government with the intent of improving access to care for eligible Tribal members. Maintaining accountability for the use of federal funds and meeting the needs of the people quickly and efficiently are of great importance.
The Code of Federal Regulation Mandates - 42 CFR Part 136 - Service Delivery Area Map
- One must be an enrolled member of the Cowlitz Indian Tribe maintaining residency in the ten county Service Delivery Area (SDA) as published in the CFR.
- Obtain prior authorization for each and every visit.
- Peace of Mind - A prior authorization lets one know funds are available, the service being requested is covered and eligibility is in place. A completed authorization ensures funds have been set aside until claims arrive for payment. Adequate notification gives staff time to assist in the best way possible.
- Alternate Resource Rule
- The PRC program is considered a “payer of last resort”. The use of other resources is required and allows for more services to more members. The PRC program is authorized to cover only the patient responsible portion after primary insurance is billed.
Becoming PRC Eligible
- Step ONE: Complete an application - CHS/PRC REGISTRATION
- Step TWO: Gather supporting documents
- Tribal ID
- Identification Cards (driver’s license or state ID, and SS card)
- Copy of Primary Insurance Cards (front and back)
- Proof of Residency (Documents that support residency: phone bill, PUD statement, vehicle registration, homeowners, or rental documentation, checking acct.)
- Application to wahealthplanfinder.org if you are uninsured/underinsured. Assistance available upon request.
- Step THREE: Submit all documents to: Cowlitz PRC, PO BOX 2429, Longview WA 98632
Your health is important to us. Please ensure all documents are provided upon initial submission. A timely review and determination period will be completed. Once eligibility has been determined additional information will be provided to include cards 1) PRC eligibility 2) Pharmacy. Each to be used as “secondary” to ensure proper billing to the primary when applicable.
We ask that you take a few moments each year to complete the annual PRC update. Correct and up to date information helps us to help you gain access to the most benefits possible.
Exceptions to the Rules
PRC eligible students who relocate outside the SDA to attend college full time may continue to access care paid for by the program while maintaining a “full time” course of study. Documentation will be required to ensure continuous coverage outside the SDA.
In addition, the program is authorized to approve prenatal care to a non-native pregnant with a PRC eligible member’s child. Please reach out to obtain more information regarding paternity and the use of alternate resources such as state medical coverage.
To ensure services are provided in a consistent manner, the PRC program follows Medicare coverage guidelines. Generally speaking, if a service is allowed by Medicare, it is also considered a PRC allowable service.
Some of the Services Covered by the Program - This list is not inclusive-please reach out to find out how PRC can assist you.
- Inpatient Medical Care
- Outpatient Specialty Care
- Primary Care
- Routine Vision Care
- Hearing Aids
- Sleep Apnea
- Diabetic Supplies
Alternate Resource Rule
As mentioned above, the PRC program is considered a “payer of last resort”. Without support from other resources such as Medicare, Medicaid, private insurance, the PRC program would be unable to provide the same level of benefits. If you are uninsured or underinsured, an application to the Health Plan Finder will be required. Staff are available to walk you through the application process in person or over the phone. Please follow the like if you’d like to complete an application on your own. wahealthplanfinder.org.
Upon completion of an application, you will be offered insurance either at no cost or with a monthly premium.
Insurance (medical, dental, optical, etc.) available at “no- cost” must be accepted. PRC funds cannot be used if “no- cost” coverage is declined. Care available at a Tribal clinic is also considered an alternate resource.
Medicare GWE funds are made available each year to ensure our Elder’s monthly premiums are taken care of. Recently, access to other Medicare benefits such as pharmacy, dental, optical, hearing and more have become available. Please don’t pass up the opportunity to expand your Medicare benefits.
Each member plays an important role in knowing what benefits are available to them through their employer or other sources such as Medicare. If an employer offers coverage to you and/or your family, please do not let the opportunity to enroll lapse.
Provider contracting is an effective way of reducing cost while increasing care. The savings are passed on to the member, often containing cost at or below the PRC allowance. If you would like more information about how to stretch the PRC dental allowance, please give us a call.
The funds we save today may go towards helping someone close to us tomorrow.
In addition to obtaining discounts for our members, PRC staff work diligently to reduce payments equal to Medicare contracted rates. This typically saves the program about $500,000.00 annually, extending the funds by roughly 50%.
Resourceful use of PRC funds allows for more services to more members.
Costco Members can save several thousand dollars on hearing aids and hundreds on eyeglasses. Ask us how to coordinate care with Costco.
- Last minute prior authorization requests can be difficult to process, please provide notification as appointments are scheduled. In some cases, same day appointments notifications may need to be reschedule.
- Provide your PRC eligibility card at each visit.
- Remind your provider of your PRC coverage if you receive a bill.
- Call to cancel any authorizations no longer needed.
- Quickly return your annual update (mailed the month prior to expiring).
- Inform the program if you move or relocate.
- Know your primary insurance benefits.
- Appropriate use of the emergency room. Your insurance company likely has an advice nurse who can assist with determining where or how to seek appropriate medical attention.
- Notification of urgent or emergent medical attention should be provided as quickly as possible but no later than 72 hours after care is rendered.
- Practice preventative care.
- Seek care with providers who are “in network” with your primary insurance to avoid out of pocket overages.
- Do not wait for an emergency to occur to register for services.
- Sign up and utilize all other resources available to you. Insurance available at no cost must be accepted.
- Please do not pay your provider up front as the program is unable to directly reimburse members. Calling for prior authorization gives staff time to work with your provider to coordinate billing & payment procedures.
Residence is defined as the dwelling or structure in which one physically “occupies” for at least nine months of the calendar year. Eligible Tribal members who relocate or leave the SDA will remain eligible for a period not to exceed 90-days. Upon return to the SDA, reestablishment of residency will be required.
Homeless or Unsheltered
One can be homeless or unsheltered in the SDA and still qualify for services. Please reach out to staff for further information and resources.
Upon receipt of a denial, a written request seeking reconsideration may be submitted to the Health & Human Services Executive Director, . If an unsatisfactory response is received, the final step in the appeal process should be addressed to the Cowlitz Health Board, Managed Care Committee.
To provide timely payment of medical care in a safe and compassionate environment supportive of a healthy Tribal community.
To be eligible for CHS you must be anenrolled member of the Cowlitz Tribeandreside within the Tribe’s ten county Contract Health Service Delivery Area (CHSDA).There are exceptions to this general rule for students and pregnant women.
If the two requirements above apply then you must submit an application forservices(Tribal Enrollment and CHS registration are two separate applications).Please be aware that CHS cannot back date eligibility. The following documentswill be required prior to an eligibility determination and in some cases annuallythereafter:
- Tribal ID
- Insurance Cards (Medicare, Medicaid, Regence, VA, etc.)
- Proof of Residency
- Birth Certificate
- Photo ID and/or Social Security Card
- Application for medical from the Department of Social and Health Services ifyou are uninsured or become pregnant, blind or disabled.
- Receiving Primary Care at the Cowlitz Tribal Health Clinic in Longview if youreside within 10-miles of the clinic.
Once you are deemed eligible two cards will be mailed to you, one for CHS and theother forpharmacy (NWPS). Please keep your cards with you and provide themas appropriate. Instructions and brochures will also be provided (please keep alldocuments provided to you for future referrance).
CHS operates within four levels of priority ranging from 1‡4, 1 being “Threat toLIFE” or LIMB, 4 being Rehabilitation. As funds become depleted the Health Boardmay make the determination that services be restricted to LIFE or LIMB only. If thisoccurs CHS staff will maintain a DEFERRED SERVICES list and services will be madeavailable as funds become available. If funds become depleted pharmacy cards maybe turned off.
CHSDA Counties: Skamania, Clark, Cowlitz, Columbia, Lewis, Thurston, Pierce,King, Kittitas and Wahkiakum.
Relocating to the CHSDA? A sixty day waiting period will apply to Membersmoving into the CHSDA, this period will begin once acceptable proof has beenprovide to the CHS office.
Contract Health Service will continue to cover Members moving from the CHSDA fora period notto exceed 90 days.
Each and Every visit requires a prior authorization. After making yourappointment you must call CHS to provide notification of the visit to includethe appointment date and name of clinic or provider. Each visit isassigned anauthorization number and funds are set aside for your visit. This will allow CHS to monitor remaining funds so that we may alert the Health Board if funds becomedepleted or low. In the event of a catastrophic injury or illness staff must be awareof available funding. Each catastrophic case is carefully monitored for alternateresources.
Time frame for notification: At least 48 hours prior to your appointment, howevertwo weeks is preferred. If you requested an authorization and there is a ZERObalance please notify staff so those funds can be used for other services.
Receiving a bill after you notified CHS?
If you provided notification of your visit to the CHS office and receive a bill fromyour provider you can assume that CHS has not been billed. Please contact theprovider and request that they bill CHS. There may be several charges associatedwith a visit that CHS is unable to foresee. DO NOT wait for a collection notice to besent, follow up with your provider as soon as possible.
If you have sustained a life threatening illness or injury and were treated at theemergency room you or someone acting on your behalf must notify CHS within 72-hours. Immediate notification is encouraged but not always possible.
An emergencyis not defined by the location of treatment but by the immediate needfor medical care. A medical necessity review will be completed by a Tribal providerwho will then make recommendations to CHS as to the appropriateness of treatment.Payment is based onthis recommendation.
If your emergency room visit is not deemed a true emergency you may becomeresponsible for your bill. All urgent care visits require PRIOR AUTHORIZATION. Ifyou are calling after hours please use the answering system to leave CHS a message.
Contract Health Service is considered “payer of last resort” by federal regulation andutilization of all alternate resources is required. Forms of alternate resource includebut are not limited to the following: Medicare, Medicaid, private insurance such asRegence or Aetna, Veteran’s Administration (VA) and tribal clinics.
To avoid CHS denials please ensure that you are meeting all program requirements.If you do not have an alternate resource (any other source of payment) and fail tocomplete the state medical application you will not be eligible for CHS payment. It isalso very important to understand the rights and responsibilities of your alternateresource such as the VA.
Denials and Grievances:Upon receipt of a CHS denial, members have 30 days tosubmit their written request for reconsideration to the Tribal Health Director. If youare not satisfied with the decision of the Tribal Health Director the third and finalstep of the appeal should be submitted to the ManagedCare Committee. If you feelthat you have a grievance or complaint, please state your case in writing to the TribalHealth Director.