Referral Process
- When referrals are initiated by your RSTHC Provider to an outside specialist or when you have additional visits or tests, the patient has the responsibility to submit the referral information to the referral coordinator to request preauthorization of payment.
- Once the preauthorization is obtained, a Referral Coordinator will assist in setting up the appointment with the outside specialist.
- If eligible for PRC, before your initial appointment and each subsequent appointment(s) please be sure the outside provider has received a preauthorization from RSTHC Referrals Department.
- If you are unable to keep an appointment or need to reschedule, please notify your Referral Coordinator as soon as possible, prior to your scheduled appointment. Please keep in mind, patients are responsible for any charges incurred from missed appointments.
- If you have additional questions regarding the referral process, please contact your Referral Coordinator at 775-329-5162
Denials
If payment for a specialty/hospital service is denied, you will be notified by the Reno Sparks Tribal Health Center Referrals Department. The most common reasons for denial are:
- Ineligibility because of failure to prove you are of American Indian or Alaska Native descent and eligible for PRC services
- Ineligibility because you do not reside within the RSTHC Purchased and Referred Care Delivery Area (PRCDA)
- Refusal to apply for and or use alternative insurance
- Visited an emergency room or urgent care for non-emergent services; did not notify RSTHC Referral Department within 72 hours of ER visit; or 30 days for elders 65 and older
- Did not follow up with your RSTHC Primary Care Provider as requested after ER visit
- Failure to provide required documents to RSTHC Referral Department (e.g. proof of insurance or other documents)
- Failure to get preauthorization for services to an outside provider and or facility
Appeals
If you want to appeal a Purchased Referred Care (PRC) denial you must provide a written response to the RSTHC’s PRC Division within 30 days of the date of the denial letter. Your appeal should identify the reasons you believe the healthcare should be paid for and any circumstances you believe should be considered as relevant. RSTHC Referral Department staff are available to assist patients in writing letters of appeal. All relevant supporting documentation should also be included with the letter. If additional information is needed, the patient will be contacted.
RSTHC’s PRC Division is the first level of appeal and will review the information, a decision will be made and you will receive a response, in writing, within 30 calendar days.
If you do not agree with the decision of the PRC Division, you can submit a second level of appeal, in writing, within 30 calendar days, to the RSTHC’s PRC Committee. The appeal will be reviewed by the RSTHC’s PRC Committee, a decision will be made and you will receive a response, in writing, within 30 calendar days.
If you do not agree with the decision of the RSTHC’s PRC Committee, you can submit a third and final appeal, in writing, within 30 calendar days to the Health Director. The Health Director will review your appeal, a decision will be made and you will receive a response, in writing, within 30 calendar days. The Health Director’s decision is final.