U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Purchased/Referred Care (PRC)

Resources

QUICK MENU: Laws  |  Regulations  |  PRC Manual  |  Priorities of Care  |  Case Management

Laws

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Regulations

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.

Indian Health Service Eligibility

Subpart B - What Services Are Available and Who is Eligible To Receive Care

Purchased/Referred Care (PRC) Requirements

Subpart C - Contract Health Services (CHS)

Medicare-Like Rates Payment

Subpart D - Limitations on Charges for Services Furnished by Medicare-Participating Hospitals to Indians

Alternate Resources

Subpart G - Residual Status

Contract Health Service Delivery Area

Issued under Federal Register (FR)/Notice Volume 72, No.119/Thursday, June 21, 2007

This notice is the revised and updated listing of CHSDAs as defined in CFR at Title 42, Part 136. This replaces and supplements the FR notice dated January 10, 1998 establishing CHSDAs 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.

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Purchased/Referred Care (PRC) Manual

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.

IHS-843-1A, Order for Health Services, the CHS purchase order form

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.

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Priorities of Care

Priorities of care and treatment for health care services will be determined on the basis of relative medical need. Medical procedures which are not funded by Federal medical care payment systems will not be considered as within IHS medical priorities. The IHS will not authorize puchased/referred care (PRC) payment for procedures not meeting the criteria. Because IHS resources are insufficient to meet all the needs of the Indian people served, refer to regulations at CFR Title 42, section 136.23(e), "Priorities for contract health services require that medical priorities be established governing authorization of CHS payment".

Detailed information on IHS Medical Priorities can be found below:

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Case Management

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