This is required by 42 CFR 136.61, Payor of last resort. Approval of PRC payment for services is considered after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to apply for alternate resources (Medicaid etc.)
Each visit to a non-IHS/tribal health care provider and the associated medical bill is distinct and must be examined individually to determine PRC eligibility. All PRC requirements must be met for each episode (treatment) of care. A patient must meet residency, notification, medical priority of care and use of alternate resources requirements of 42 CFR 136.23, 136.24 and 136.61 in order to be eligible for PRC.
Example: If a PRC authorization is issued, RSTHC PRC will pay the first medical treatment. Follow-up care or additional medical care are to be done at the nearest accessible IHS or tribal facility or will require approval with a new PRC authorization. If this process is not followed, the patient will be responsible for the expense.
Referrals are not a guarantee for payment. Referral is a recommendation for treatment/test only. The PRC program must review the referral to make the determination for IHS/tribal approval of payment. All PRC eligibility requirements must also be met. See 42 CFR 136.23, 136.24 and 136.61.
It is required under 42 CFR 136.61, Payor of last resort. The Indian Health Service is not an entitlement program, and therefore funding for PRC is not guaranteed by the Federal government. Alternate resources allow PRC funds to be conserved, thereby providing health care for more Indian beneficiaries.
