Purchased/Referred Care (PRC)

Meet Our Team!

LISA POWELL

PRC FRONT DESK CLERK

P: (231) 242-1607

Lisa is the first employee patients should contact for the PRC Program. She issues reference numbers for appointments outside of Mina-Mskiki Gumik, ensures phone calls go to the appropriate staff, and assists patients with any questions or concerns they may have regarding PRC coverage.

NICOLE DAILY

PATIENT REGISTRATION SPECIALIST

P: (231) 242-1747

Nicole is one of the first employees to greet patients entering the Health Department. She is checks in every patient for each clinic, ensuring demographics are up-to-date and are compliant with our federal regulations. She is available to assist patients with any general questions regarding the LTBB Health Department.

AMY MASSEY

PATIENT BENEFIT SPECIALIST

P: (231) 242-1616

Amy works with patients to check Medicaid eligibility and can submit Medicaid applications. Any questions about how to apply for Medicaid or the status of an application, can be directed towards her.

ABIGAIL DAWSON

LTBB SPONSORSHIP SPECIALIST

P: (231) 242-1748

Abigail works closely with patients that are eligible for PRC’s Medicare Part B and Part D Reimbursement Programs. She is extremely busy during the months of January and July while she works to process reimbursements to our Tribal Community nationwide.

MEGHAN FISCHER

PRC REFERRAL SPECIALIST

P: (231) 242-1600, option 3

Meghan works alongside the LTBB Clinical Staff to ensure PRC eligible referrals are approved through Managed Care, prior authorizations from insurances are obtained, and referral documentation is submitted to the outside provider.

MARCIA SUTTON

PRC SPECIALIST

P: (231) 242-1600, option 3

Marcia maintains a wealth of knowledge regarding the PRC Program. She assists patients through complex outside referrals, processes dental claims, reimbursement cases, approved mileage/hotel accommodations, and is a member of the Managed Care meetings.

CHRIS WEMIGWASE

PRC ASSISTANT

P: (231) 242-1600, option 3

Chris processes payments for outside providers that have been approved for coverage by PRC. She also assists patients with questions or concerns regarding account payments or statements they may receive in the mail.

NEEWIN WEMIGWASE

PRC ASSISTANT

P: (231) 242-1600, option 3

Neewin processes payments for outside providers that have been approved for coverage by PRC. He also assists patients with questions or concerns regarding account payments or statements they may receive in the mail.

LISA BROOKINS

PRC ASSISTANT

P: (231) 242-1600, option 3

Lisa processes payments for outside providers that have been approved for coverage by PRC. She also assists patients with questions or concerns regarding account payments or statements they may receive in the mail.

BERT ROUSSEAU

CITIZEN PROGRAMS SPECIALIST

P: (231) 242-1752

Bert is the benefits coordinator for the Hearing Aid, Elder’s Dental, and Elder’s Vision Programs. She is available to take care of reimbursements or questions about any of these programs.

About Purchased/Referred Care (PRC)

PRC is an Indian Health Service that is a U.S. federally funded program run by the Little Traverse Bay Bands of Odawa Indians (LTBB) Health Department. It is the means used to pay for services that cannot be provided at the Mina-Mskiki Gumik Clinic for patients who are eligible for coverage. PRC is the payer of last resort. All insurances, including Medicaid, or other resources must be billed and exhausted before payment is made through PRC.

Please note: This program has strict federal guidelines that must be followed. PRC is not an entitlement program or insurance plan. Payment can only be guaranteed through prior authorization with PRC.

To be eligible patients must meet the following criteria:

• • Completed the LTBB Patient Registration Packet,
  • Be a tribal citizen or descendent of LTBB
    -OR-
    Be a tribal citizen of a federally recognized tribe with socio-economic ties to LTBB,

• • Provide Tribal Identification Card
    -OR-
    Proof of descendency,

• • Provide Driver’s License, State Identification, or Government Issued Picture Identification,
  • Two proofs of residency (i.e. Tribal ID, Driver’s License, bills, voter registration, leases, automobile registration).
    • Proof must be physical address, not RV park or P.O. Box.
  • Provide proof of insurance(s) or valid letter of Medicaid determination from your local DHS office.

There are also patients who can temporarily qualify for PRC eligibility. These include:

• • Non-native pregnant women who are carrying a native child can qualify for coverage for the duration of the pregnancy, plus 6-weeks post-partum.
    • SPECIAL REQUIREMENTS APPLY. Please call our mainline for further details prior to initial obstetric appointment.
  • Stepchildren and adopted children of an enrolled LTBB member are eligible for PRC until the age of 19.

How does it work?

When a patient meets the eligibility requirements for PRC, they can receive coverage through the program. However, payment cannot be guaranteed without prior authorization. There are two ways a patient can receive prior authorization.

First, is by obtaining approval from the Managed Care team. The team’s function is to review and prioritize PRC referral requests and notifications regarding emergency episodes of cared based on Medical Priorities of Care, as well as to review and monitor the referral and expenditure of PRC funds. The team consists of the Clinic Nurse Manager, PRC Referral Specialist, PRC Specialist, and the PRC Manager. Managed Care meets on a weekly basis on Tuesdays at 10 am. However, the date is always subject to change. Patients will receive a letter in the mail with the determination for coverage.

Services and procedures that require Managed Care approval include, but are not limited to:

Second, is by obtaining a reference number from the Health Services Navigator. There are certain services and procedures that do not require the approval of the Managed Care team. If a patient maintains yearly compliance with PRC, they may call the Health Services Navigator 24 hours in advance of their appointment to obtain a reference number.

Services and procedures that do not require Managed Care approval include, but are not limited to:

If a patient has any questions or concerns regarding these authorizations, they should contact the Health Services Navigator at (231) 242-1600.