Purchased Referred Care

Purchased Referred Care (PRC)

Oyate Health Center (OHC) provides many medical and health services that are referred to as Direct Care. If OHC cannot provide you with the healthcare services you need on campus, your OHC provider may make a referral request to an outside medical specialty clinic. A Managed Care Committee (MCC) will determine if OHC will approve, deny, or defer your referral.

Patients must meet the following requirements to be eligible for PRC services

Proof of Residency in Pennington County, South Dakota
Proof of Tribal Enrollment, or Proof of Descent of an Enrolled Member, of a Federally Recognized Tribe
Medical Necessity
72 Hour Notification of Emergency Services (30 days for elderly or disabled)
Use of Alternate Resources
Please reference 42 C.F.R. Part 136 for complete eligibility requirements

PRC is not an entitlement program. If your OHC provider team makes a referral, it is important that you ensure it is approved for payment. This guarantees payment by the OHC PRC program. If you choose to receive referred services without approval, you will be responsible for the bill.

Referral Process

After the OHC provider enters a referral for you to receive outside care, the Managed Care Committee (MCC) which consists of key staff including the Chief Medical Officer, meet on the referral to determine eligibility. Much like the Indian Health Service, OHC can’t approve all referrals. Referral approval must meet all eligibility requirements. There are also limited funds available for referred care. Emergency and urgent referrals receive priority and we approve as many referrals as we possibly can. Referrals are not unlimited. All referrals are reviewed and prioritized based on medical necessity and the availability of funds. The referral is either approved, denied or deferred. If a referral is denied or deferred, the patient may elect to receive services at their own expense. In some cases, an approved referral is limited to one medical treatment/appointment. Please call PRC prior to any follow-up appointments, labs, x-rays or for referrals to another specialist/facility for approval. You may need to contact your Primary Care Provider to enter another referral request.

Residency Requirement

In order to be eligible for Oyate Health Center’s PRC services, you must permanently reside in the PRC delivery area. Oyate Health Center’s delivery area is Pennington County, SD. PRC will require your for proof of residency to verify your eligibility.

Acceptable forms of proof of residency:

Current Mortgage or lease agreement
Current Utility Bill (Water, Electric, Gas, Heat)
Current residential Land Line phone, Cable or Internet Bill with service address
Current unexpired Drivers License or State ID (must have gold star)
Unexpired Tribal ID with Pennington County SD address.
Prior year tax documents – accepted by IRS Voter Registration within the last year
Vehicle Insurance Records or Vehicle Registration Records current in Pennington County, SD
Current Federal/State/County mail (e.g. IRS, SD DSS, SSA)
Current Pay Stub showing proof of employment and employers contact info.
College students may be eligible. For complete details on guidelines please inquire with PRC.
Call PRC for Eligibility Requirements

Unacceptable forms of proof of residency: Post Office Boxes or notarized statements. Cell phone Bills, Bank Statements, Junk Mail and addressed Documents outside of Penn. Co. SD

** PRC reserves the right to request additional information & verify documents submitted ***

Important Facts

OHC is payer of last resort and all other resources such as Medicaid, Medicare, Private Insurance, Workman’s Compensation or the VA are considered primary payers. These resources must be exhausted first & OHC’s PRC will be secondary payer. Failure to provide primary payer information may result in a delay in payment of your bill. The outside providers have their own billing process. They will bill OHC PRC for any approved service. It is important to ensure you have an approved referral before services are provided.

Should you have an emergency situation that requires you to go to a hospital emergency department for care, you must notify PRC within 72 hours of the emergency room visit. Elders (65+) and people with disabilities have an extended notification period of 30 days. Failure to notify OHC PRC of an ER visit could result in denial of payment.

Appeal Process

If you receive a denial from OHC PRC, you may appeal this decision in writing within 30 days of receiving your denial letter. The appeal letter should include the denial number, the date of service denied, & the written justification for the appeal. PRC will send a letter informing the patient of the appeal status. If you need assistance with the appeal process, don’t hesitate to contact the PRC office. Deferred referrals do not have appeal rights.