Purchased/Referred Care (PRC)

Purchased/Referred Care (PRC)

(Formally known as Contract Health Services)

Main Line: (231) 242-1600

Fax: (231) 242-1617

Meet Our Team!

Tracey Conant

HEALTH SERVICES NAVIGATOR

P: (231) 242-1600

Tracey issues reference numbers for appointments outside of Mina-Mskiki Gumik; manages the Elder’s Dental Program and the Hearing Aid Program; and assists patients with any questions or concerns they may have regarding PRC coverage.

ASHLEY DAVIS

PATIENT BENEFITS SPECIALIST

P: (231) 242-1752

Ashley assists patients with questions or concerns regarding their health benefits. She also works with patients that have no insurance to meet PRC’s federal requirement by screening or applying for Medicaid once per year.

VALORIE GLAZIER

LTBB SPONSORSHIP SPECIALIST

P: (231) 242-1748

Valorie works closely with patients that are eligible for PRC’s Medicare Part B and Part D Reimbursement Programs. She also assists the Patient Benefits Specialist in processing Medicaid applications and insurance questions.

KELLI PAMP

CENTRAL REGISTRATION CLERK

P: (231) 242-1747

Kelli checks in all patients for their appointments at the LTBB Health Department. She ensures patient demographics are up-to-date and are compliant with our federal regulations.

MEGHAN FISCHER

PRC REFERRAL SPECIALIST

P: (231) 242-1600

Meghan works alongside the LTBB Clinical Staff to ensure referrals are submitted to outside providers and approval is obtained through PRC’s Managed Care.

MARCIA SUTTON

PRC SPECIALIST

P: (231) 242-1600

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 a member of the Managed Care meetings.

CHRIS WEMIGWASE

PRC ASSISTANT

P: (231) 242-1600

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

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

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.

JADE BARNES

PRC MANAGER

P: (231) 242-1600

Jade oversees the PRC Program. She works closely with her team to keep operations running smoothly. She also assists with complex referrals, maintaining relationships with providers, and supporting patients with unresolved issues.

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:

    • ALL referrals to outside/specialty providers
    • EGDs
    • Physical Therapy
    • Orthotics
    • MRIs
    • ER or Urgent Care Visits
    • Injections, Epidurals, or Infusions
    • Biopsies
    • Allergy Testing
    • Sleep Studies
    • Apnea Link, CPAP Machine, or BYPAP Machine
    • Myelograms
    • Bone Scans
    • Holter Monitors
    • EMGs
    • Dental Extractions

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:

    • Labs
    • X-rays
    • Ultrasounds
    • CT Scans
    • Dopplers
    • EEGs
    • EKGs
    • Echocardiograms
    • Heart Catherizations
    • Yearly Dilated Diabetic Eye Exams
    • Bone Density Tests
    • Stress Tests
    • Routine Colonoscopies
    • Routine Mammograms
    • NIVA Studies

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

PRC INFORMATIONAL FLYERS