The regulations establish the principles and program requirements for carrying out the PRC program. The PRC program regulations are published in the Code of Federal Regulations at Title 42 and in the Federal Register.
Subpart B - What Services Are Available and Who is Eligible To Receive Care
Subpart C - Purchased/Referred Care (PRC)
Subpart D - Limitations on Charges for Services Furnished by Medicare-Participating Hospitals to Indians
Subpart G - Residual Status
This notice is the revised and updated listing of PRCDA s as defined in CFR at Title 42, Part 136. This replaces and supplements the FR notice dated January 10, 1998 establishing PRCDA s and FR notice dated August 25, 1988 establishing Health Service Delivery Areas. The listing provides the Tribe/Reservation and the Counties/State under the scope of the program. Information on background and procedures on determining the delivery area of a Tribe is also provided.
The manual defines effective management based on Congressional legislation, funding, and authority for PRC program. The PRC program's responsibility is in support of the IHS direct care services by contracting services with non- IHS providers for health care services. The manual is an application of the legislation with the governing regulations, policies, and other guidances published for the program's management.
The program management is the administrative resources, patient eligibility, contracting (authorizing purchase), fiscal functions, alternate resources identification, PRC delivery area, Catastrophic Health Emergency Fund (CHEF), patient education, provider education, appeal process, applying the IHS medical priority requirements, fiscal intermediary, patient transportation, and PRC -related information systems.
When authorizing a patient medical services for PRC payment, the PRC will issue the "Order for Health Services", IHS-843-1A form (the PRC purchase order form), to the provider contracted to provide medical care for the patient. Authorization occurs when the patient is determined to be PRC -eligible. The PRC program then authorizes the patient to receive specific services with the services scheduled by PRC staff. Exceptions to the IHS-843-1A authorization prior to medical services provided occur in urgent emergency care situations. The potential authorization is dependent on the patient complying with all PRC requirements for eligibility. Requirements of PRC program include notification within 72 hours of the episode of care, determination that the level of medical need is within the IHS medical priority, provision of medical summary to PRC after discharge, use of available or potential alternate resources, and residence of patient within his health care service delivery area. If the patient is compliant with federal requirements and authorized by PRC , the IHS-843-1A will be issued. The provider will complete the bottom part of form and mail it with an EOB to the PRC fiscal intermediary for payment. Provided is the IHS-843-1A fill-in form for use by PRC programs as an alternative when the IHS data system is not available to process/issue the form.