This page contains information regarding program functions and funding; it is intended for use primarily by PRC program staff.
The PRC program responsibility is to administer and manage the contracting of health care services with non-IHS providers for services of Indian people residing on or near reservations. The PRC funds are used to supplement and complement other health care resources available to eligible Indian people. This responsibility is accomplished through the staff located at the IHS Headquarters in Rockville, Maryland and at each of the twelve Area Offices located across the nation. PRC staff can also be found at IHS and Tribal facilities. The program directory on this website provides the twelve Areas and the contact numbers for each of these PRC program locations.
The PRC funds are utilized in situations where: (1) no IHS direct care facility exists, (2) the direct care element is incapable of providing required emergency and/or specialty care, (3) the direct care element has an overflow of medical care workload, and (4) supplementation of alternate resources (i.e., Medicare, private insurance) is required to provide comprehensive care to eligible Indian people.
The program accomplishes the responsibilities or functions with dedicated PRC program staff. The staff or Full time Equivalent (FTE) provide comprehensive administrative management functions using a Headquarters criteria and the staffing module to estimate the requirements to perform the functions. The standards are derived from the IHS Resource.
Requirements Methodology (RRM) identifies the workload and related functions:
- Patient eligibility for contract health care.
- Processing procurement orders for requested contract health services.
- Assistance to patients with alternate resources compliance.
- Correspondence related to PRC authorizations for payment or non-payment.
- Tracking allocation of PRC funds to assure the program stays within budget.
- Coordination of activities associated with contract health care.
The key variable is number of PRC authorizations for health care for eligible individuals. Program functions for Area and Service Units are located in the IHS Manual, Part 2, Chapter 3. "Contract Health Services".
The minimum fixed staffing criteria:
- PRC Director at fixed minimum
- Secretary at fixed minimum
- 1.0 FTE for each $5 Million budgeted for PRC care (Non-tribal funds)
- 0.25 FTE for each $15 Million in Tribal contract/agreements.
- PRC Manager; 1.0 FTE for each facility that processes 100 or more PRC authorizations for health care services.
- Utilization Review staff; 1.0 FTE for every 10,000 PRC authorizations for health care services.
- PRC staff: 1.0 FTE for every 2,000 PRC authorizations for health care services. At facilities that have over 100 PRC authorizations a year.
The PRC program developed and established prototype position descriptions for PRC staff. The prototypes descriptions received Headquarters personnel office approval in 1996. As prototypes for the area and service unit positions, the areas will be responsible for completing the classification of the position descriptions for their individual area. The PRC prototypes have been developed for the following positions:
OPERATING UNIT (SERVICE UNIT)
MEDICAL CLERK (O/A), GS-679 POSITIONS
- Medical Clerk (O/A) GS-679-04 [DOC - 64 KB]
- Medical Clerk (O/A) GS-679-05 [DOC - 82 KB]
- Medical Clerk (O/A)/Medical Assistant GS-679-06 [DOC - 58 KB]
HEALTH SYSTEM SPECIALIST POSITIONS
- Health System Specialist GS-671-05-SU [DOC - 72 KB]
- Health System Specialist GS-671-07-SU [DOC - 68 KB]
- Health System Specialist GS-671-09-SU [DOC - 68 KB]
- Health System Specialist GS-671-11-SU [DOC - 72 KB]
- Health System Specialist GS-671-11-Area [DOC - 67 KB]
- Health System Specialist GS-671-12-Area [DOC - 58 KB]
- Supv. Health System Specialist GS-671-13-Area [DOC - 56 KB]
- Managed Care Consultant GS-671-13-Area [DOC - 101 KB]
The program's role is to provide effective management of the PRC program. Tools for accomplishing the administration and management of purchasing of health care services are: the guidance materials, the PRC manual, procedures, policies, and regulations that have developed from the legislation for the health care of Indian people. The PRC funds for purchasing health care services come from Congressional appropriations determined from the President's yearly budget. The appropriation funding may vary from year to year; with each year the program submits the data on PRC services provided and the expenditure of the PRC funds for that care. Related program changes are shared through print, meetings, & trainings with staff.
The program operates the PRC program within the limits of available funds, with the authority for the operation of the PRC Program to Area Directors and the Service Unit Directors (SUD). When applicable to clarify and explain PRC policies and procedures to contractors, refer to Public Law (P.L.) 93-638, the Indian Self-Determination and Education Assistance Act (ISDEAA). For more information, refer to the Code of Federal Regulations (CFR), Title 42, §§ 136.21 - 136.25. The manual should not be cited as authority for making decisions on eligibility or payment denials. The CFR is the proper citation for correspondence to providers and American Indian/Alaska Native patients.
Additional program tools used in administering and managing the program are the Catastrophic Health Emergency Funds (CHEF), fiscal intermediary (FI), management information system (MIS), quality assurance, and the new Medicare-like rate payment. The CHEF is funded from a separate Congressional funding that is administered at programs headquarters based on legislation to provide a funding for patients' high-cost cases. The PRC program's CHEF funding normally depletes before the end of the fiscal year. The Fiscal Intermediary (FI) is a contracted function for the payment of the authorized PRC services purchased. The FI processes the PRC-authorized purchase orders from the claims submitted by the non-IHS providers, pays the reviewed approved claims, and provides data reports. The PRC MIS is a data system module of the IHS information system for entering patient PRC services. The quality assurance is non-recurring funding to support initiatives and projects for quality patient care related to services and funding accountability from contract providers. The new Medicare-like rate legislation provides for IHS & Tribal programs to pay for in-patient services at the Medicare-like rate to non-IHS providers.
The Program Staff section will continue to be developed for program-related information.