The PRC program must be notified of requests for authorization of payment for health care services from a non-IHS provider. Notification requirements for non-emergency medical care and the requirements for emergency care are provided in the regulations. These requirements must be met before a authorization PRC authorizing official will be made for a purchase order to the provider. The patient, provider, hospital or someone on behalf of the patient must contact a PRC authorizing official of the need for PRC. Notification requirements apply to all categories of eligible persons including students, transients, and persons who leave the PRC delivery area.
A patient must meet the notification requirements set forth in Federal regulations located in Title 42 of the Code of Federal Regulations (CFR). An excerpt from 42 CFR is provided below for your information. For more information regarding the PRC notification requirements please contact the IHS or tribal facility at your location.
Code of Federal Regulations at Title 42-Public Health Services, Department of Health and Human Services, Part 136-Indian Health
Subpart C - Contract Health ServicesSec. 136.24 Authorization for contract health services.
- No payment will be made for medical care and services obtained from non-Service providers or in non-Service facilities unless the applicable requirements of paragraphs (b) and (c) of this section have been met and a purchase order for the care and services has been issued by the appropriate ordering official to the medical care provider.
- In nonemergency cases, a sick or disabled Indian, an individual or agency acting on behalf of the Indian, or the medical care provider shall, prior to the provision of medical care and services notify the appropriate ordering official of the need for services and supply information that the ordering official deems necessary to determine the relative medical need for the services and the individual's eligibility. The requirement for notice prior to providing medical care and services under this paragraph may be waived by the ordering official if:
- Such notice and information are provided within 72 hours after the beginning of treatment or admission to a health care facility; and
- The ordering official determines that giving of notice prior to obtaining the medical care and services was impracticable or that other good cause exists for the failure to provide prior notice.
- In emergency cases, a sick or disabled Indian, or an individual or agency acting on behalf of the Indian, or the medical care provider shall within 72 hours after the beginning of treatment for the condition or after admission to a health care facility notify the appropriate ordering official of the fact of the admission or treatment, together with information necessary to determine the relative medical need for the services and the eligibility of the Indian for the services. The 72-hour period may be extended if the ordering official determines that notification within the prescribed period was impracticable or that other good cause exists for the failure to comply
In addition, Section 406 of P.L. 94-437, as amended allows the elderly and disabled 30 days to notify the IHS of emergency medical care received from non-IHS medical providers or at non-IHS medical facilities. The following definitions for elderly Indian and disabled Indian are to be used until further defined and published in the Federal Register. An elderly Indian means an Indian who is 65 years of age or older. A disabled Indian is an Indian who has a physical or mental condition that reasonably prevents him/her from providing or cooperating in obtaining the information necessary to notify the IHS of his/her receipt of emergency care or services from a non-service provider or facility within 72 hours after the non-service provider began to deliver the care.