Purchased/Referred Care (PRC)

Purchase Referred Care is Specialty medical and dental services provided by private outside doctors and hospitals

Purchased/Referred Care Services

When specialty medical or dental services are not available at Nimiipuu Health (NMPH), the patient’s NMPH primary care provider will order a referral to an outside physician or facility. A referral from NMPH is NOT a guarantee of payment. Payments are authorized based on guidelines/patient eligibility criteria and are subject to availability of funds, which are not always available. 

Eligibility is determined by patient residency and enrollment status in a federally recognized Indian Tribe.

Persons to whom PRC will be provided:

  1. Enrolled Indians and their descendants who live within the boundaries of the Nez Perce Tribe Indian reservation; or
  2. Enrolled Nez Perce Tribal members or 1st generation Nez Perce descendants who do not reside on the Nez Perce reservation, but reside within the boundaries of the Nez Perce Tribe’s Purchased/Referred Care Delivery Area (PRCDA) which includes the counties of Nez Perce, Latah, Clearwater, Idaho, and Lewis; or
  3. Members of another Tribe who reside within the PRCDA; and

Maintain close economic and social ties determined by the governing body of the Nez Perce Tribe.

Application for close economic and social ties will require proof of

  1. membership in a federally recognized tribe; and
  2. full-time residence within the PRCDA; and
  3. full-time employment with the Nez Perce Tribe; or
  4. marriage to an enrolled Nez Perce tribal member.

Things that may affect PRC payment

  1. Not PRC eligible per the policies/guidelines
  2. No availability of funds
  3. Change in residency with no notification to NMPH
  4. New patient 90 day waiting period
  5. Patient chart not up to date (required every 12 months)
  6. Patient did not apply for alternate resources as required

PRC eligible patients with a Nimiipuu Health referral must:

  • Report all outside provider appointments to the PRC Hotline 208-621-4955 at least 72 hours prior to the appointment
  • Provide their purchase order number and complete insurance information to all outside providers to ensure accurate billing information.
  • Reschedule referral appointments with outside providers, if needed, and notify PRC of the new appointment date. PRC will NOT pay for “no show” or “missed” appointment charges.
  • bring all bills, statements, collection notices from outside providers to the PRC office as soon as possible

Emergent or Acutely Urgent Medical and Dental Services

NMPH patients seen by outside facilities for emergent/ acutely urgent care, without prior approval in the form of a NMPH referral and a prior authorization or purchase order number from NMPH PRC staff, are considered self-referrals.  Self-referrals require a review of patient’s eligibility status, compliance with notification requirements (72 hours within receiving care, 65 years and older-30 days to notify), and clinical/medical information by PRC staff prior to approving or denying emergency services or self-referrals for PRC/CHS payment. Services provided must not be accessible/available at NMPH and must be within current medical priority.

PRC eligible patients incurring pharmacy costs when the NMPH Pharmacy is closed may be reimbursed. Patient must submit a request for reimbursement with the receipt and prescription drug information. Only those issued by emergency room physician/provider will be reimbursed.

Denials/Appeals

A person denied PRC will be notified in writing. They may request reconsideration of the denial by submitting a written letter of appeal to the PRC within 30 days of receiving a denial notice

Levels of Appeal

  1. PRC Supervisor
  2. Nimiipuu Health Executive Director

Pregnancy, Obstetrical (OB), Maternity Care & Newborn Care

All pregnant women will be required to apply for State Medicaid within 30 days. PRC eligibility will be suspended until a Medicaid notification of approval or denial is received from the patient. Medicaid denials for valid reasons such as “over income” are acceptable.

PRC will not assume responsibility for the cost of services related to pregnancy, delivery, and postpartum care when the patient fails to respond to requests from NMPH or State Medicaid.

Non-Indian women pregnant with an eligible Indian child will be eligible for PRC through six weeks postpartum. Only pregnancy related services ordered by referral from NMPH will be considered for payment.

Bills, Statements, Collection Notices

To ensure prompt and accurate payment, patients who receive a bill of statement from an outside provider must call the number provided on the bill to confirm correct billing information. Private insurance is the primary payer and Nimiipuu Health is secondary. If there is no private insurance, Nimiipuu Health is primary.

Please bring all bills, statements, collection notices from outside providers to the PRC office as soon as possible. Patients may drop them off with the Patient Care Coordinator in the NMPH lobby, bring it to the PRC office, or drop them in the secure drop box outside the NMPH front entrance.

Address

Purchased/Referred Care

P.O. Drawer 367

Lapwai, ID 83540

Nimiipuu Health Purchased/Referred Care Contacts: (208) 843-2271

Trina – PRC Referral Specialist – Ext 2853

Cheree – PRC Technician – Ext 2860

Celiisa – PRC Technician – Ext 2989

William – PRC Data Entry Technician – Ext 2813

Yvonne – PRC Claims Specialist – Ext 2817

Pam – PRC Supervisor – Ext 2836

PRC Fax Number:  208-843-268

Purchased/Referred Care Hours

Monday, Tuesday, Thursday & Friday
8:00am – 12:00pm & 1:00pm – 5:00pm

Wednesday
1:00pm – 5:00pm only

Saturday & Sunday
Closed