PRC Application

PRC Application Information

Purchased Referred Care Services

• Email: ohc_prc_services@oneidanation.org
• Phone: 920-869-2711
• Fax: 920-869-1782
• Mailing Address: Oneida Health Center, ATTN PRC Dept, PO Box 365, Oneida, WI 54155

The Purchased Referred Care (PRC) program is for medical, dental, vision, behavioral health and prescription services that are not available through the Oneida Comprehensive Health Division (OCHD). PRC is not an entitlement program, and a referral does not imply the care will be paid by PRC or the Health Center. If PRC is requested to pay, the patient must meet:

• Residency and notification requirements
• Medical priority
• Use of alternate resources
• Patients must receive primary care at OCHD and be an active patient within last three years to be eligible. 
• Have an approved referral on file for PRC to pay any claims on behalf of the patient.
  • • Backdated referrals need supervisory review.

Eligibility Requirements

1.  Be an enrolled member, be eligible for enrollment, or a descendant of the Oneida Nation
residing within Brown or Outagamie Counties.

2.  Other federally recognized tribal members and descendants residing within the Oneida Nation Reservation boundaries.

1.  Other federally recognized tribal members or descendants who maintain close social and/or economic ties with the Oneida Nation residing within Brown or Outagamie counties.
   1.  Married to an Oneida Nation member or descendant. Proof of marriage required.
   2.  Have custody of Oneida Nation enrolled or descendant minor children.
   3.  Employed by the Oneida Nation. Proof of employment required

3.  Patients must receive their primary care from an Oneida provider, per specialty (Medical, Dental, Optical, Behavioral Health)

4.  For minor dependents who reside with both parents at separate addresses, eligibility will be based on what address is used for enrollment in school, or what address schooling is being facilitated at. Verification of school enrollment may be requested

5.  Students who meet the above guidelines at their permanent residence prior to leaving for school can continue PRC eligibility until 180 days after completion of their studies.

1.  Students must provide proof of full-time enrollment by submitting their school schedule to PRC for verification every semester.

6.  A person who is eligible but leaves the Oneida PRC Delivery Area (PRCDA), which is identified as Brown and Outagamie County, will continue to be eligible for 180 days.

1.  Those that live in another state part time, written notification of when they leave and return to the Oneida Nation PRCDA is required before any claims will be paid to providers that are outside the area.

7.  Foster children: eligible children who are placed in foster care outside the Oneida Nation PRCDA by order of a court and were eligible for PRC services at the time of the court order shall continue to be eligible for PRC services while in foster care.

8.  Native children adopted by non-Native parents: Enrolled and descendant Native children adopted by non-Native parents must meet the general eligibility criteria to be eligible for PRC services (reside within the Oneida Nation PRCDA).

9.  Non-Native woman pregnant with an eligible Native American’s child for the duration of her pregnancy through postpartum if prenatal care is done through Oneida Community Health Center (OCHC) or referred out by an OCHC provider. Coverage will be for the mother’s prenatal and delivery costs and for the baby’s delivery costs. If prenatal care is not done at OCHC or not referred by an Oneida provider, the delivery and birthing costs for mom and baby will be the responsibility of the patient/parents.

1.  A written paternity acknowledgement form will need to be on file for unmarried parents.

10.  Patients who have no insurance will need to be screened by the Medical Benefits Coordinator annually (or as needed) to determine eligibility for alternate resources. Failure to follow up with additional requests/information will result in denial of payment. If patients lose insurance, they must notify PRC and be screened within 30 days of their coverage ending before. PO any payments or new referrals will be issued, or they will be responsible for any outstanding claims after their insurance ended. Any new insurance needs to be reported to PRC right away.

Required Documentation

1.  Proof of Tribal affiliation; Tribal ID, descendancy paperwork (will be kept on file)

2.  ANNUALLY or WHEN CHANGES OCCUR

1.  PRC Application completed with supporting documents
   1.  Proof of residency (POR) showing name, physical address, and visibly dated within the last 60 days (annually). See list of acceptable documents on page five (5).
   2.  PO Boxes are not acceptable for POR.
   3.  Notice from homeless shelters will be considered as temporary POR, valid for one year, or until a new address is provided
       NOTE: Additional forms of POR may be requested if there is an address discrepancy.
   4.  Insurance information: name of Carrier, member ID, Group ID, copy of insurance card and in network provider information.
2.  Any changes with insurance need to be disclosed to PRC and Patient Registration immediately after the change. Failure to do so may result in denial of referrals and payments of claims.
3.  If patient loses insurance benefits, patient MUST be screened for alternate resources before any further referrals or payments of claims will be processed.

3.  PRC eligibility will be approved for up to one calendar year from the date of receipt of application. Approved time frame could be less for students and temporary POR patients.

1.  A new PRC application and/or POR is needed if patient moves to new address, or a new PRC eligible dependent is added to the household.

4.  Provide legal guardianship/Power of attorney paperwork to Medical Records for patients that are not old enough/not able to make medical decisions for patients that are not legally able to do so themselves (i.e. grandparents taking care of grandkids, parents taking care of adult aged children).

5.  Once patient turns nineteen (19), they are no longer able to be on parent(s) application. They must provide their own application, proof of residency and tribal affiliation.

Emergency Situations

1.  For after-hours urgent or severe medical problems, go directly to the hospital and notify PRC within 72 hours. Tribal elders aged 55 and over are allowed 30 days to notify PRC. All ER and Urgent Care visits require notification even with an active referral for care for a condition that is related to the emergency. This includes ambulance calls where transport is not done.

2.  Unsure about a medical situation? Call OCHC to seek medical advice by calling 920-869-2711, which is available after hours by an answering service. An on-call provider will be contacted to call you.

3.  After hours prescriptions:

1.  Utilizing an outside pharmacy is for emergency or pre-approved situations. 
2.  Oneida’s preferred provider is Walgreens located at 116 North Military Ave, Green Bay, WI 54303.
3.  Oneida members will need to present their insurance information (if applicable) and Tribal ID/descendent letter. Unfortunately, this only applies to Oneida enrolled/descendants.
4.  If it is not possible to utilize this pharmacy or if Tribal ID is not presented/available, keep original paperwork and receipts to request reimbursement. Submit reimbursement requests to PRC Supervisor.
   1.  Patients must be PRC eligible for reimbursements.

           Please note: Patients need to utilize the Oneida Pharmacy if it is open, or you may not be eligible for reimbursement.

4.  When seeking emergency care outside of Brown or Outagamie County, follow the same guidelines above.

1.  Obtain information regarding the facility you went to and provide that information when you notify Oneida of the visit.
2.  Request records be sent to your Oneida provider at OCHC.

Priorities of Care

1.  Priorities of care and treatment for health care services will be based on relative medical need. Medical procedures which are not funded by Federal medical care payment systems (such as Medicare) may not be within PRC’s medical priorities. PRC does not cover items that are not covered by Medicare, not medically necessary, are experimental/investigational, second opinions or otherwise excluded by OCHD management team.
2.  Medical priority levels:
   1.  I. Emergent or Acutely Urgent Care Services
   2.  II. Preventive Care Services
   3.  III. Primary and Secondary Care Services
   4.  IV. Chronic Tertiary Care Services
   5.  V. Excluded Services
3.  Refer to PRC to see which medical priorities are being covered at the time of your referral.

Patient Responsibilities

1.  Submit a completed PRC application annually or when changes occur.

2.  Submit Proof of Residency (POR) with the application or when there is an address change.

1.  Applications will be considered incomplete if the POR is not included and the application is not complete.

3.  Submit all bills associated with your referred and emergency visits to PRC as soon as you receive them. PRC cannot make payments to collection agencies

4.  Notify PRC within 72 hours after seeking emergency room care or urgent care; Elders 55 and over have 30 days to notify PRC.

5.  Present insurance cards to outside providers for all services.

6.  Request your records be sent to your OCHD provider.

7.  Respond to your insurance carrier if they request additional information.

8.  Take note of the number of approved visits and authorized date range on your referral form. If more visits are needed or an extension of the date range is needed, contact your OCHD provider. PRC will only cover the visits/services specified in the referral.

9.  For patients with no insurance, apply for alternate payer resources as requested and respond to all requests for additional information (i.e., provide 30 days’ income, income verifications). Failure to comply with application requirements will result in denial of PRC eligibility.

10.  Immediately notify OCHD Patient Registration and PRC if you have changes to your:

1.  Contact information (phone and/or address) as it may require an updated application and POR
2.  Change or loss of insurance as it will require an alternate resource screen
3.  Removal/addition of dependents

11.  PRC must be notified within 30 days of a new baby/dependent and complete a new PRC application adding the newborn to PRC eligibility for the household. Failure to do so may result in any outstanding claims being the patient/parent responsibility.

Appeal Process

1. Patients whose claims/referrals are denied for PRC services may request reconsideration of the denial for services/payment

2.  An appeal of a denial must be submitted in writing and be received by the due date (mail postmark, date stamp by OCHC) listed on the appeal letter to the PRC supervisor at Oneida Community Health Center, PO Box 365, Attn: PRC Supervisor, Oneida, WI, 54155.

3.  Appeal must indicate what they are appealing to include the date of service, provider, case number, and why the denial should be overturned; if applicable, include supporting documentation such as the denial letter, phone records, etc.

4.  PRC supervisor or designee has 10 business days from the date the appeal is received to issue a decision.

1.  If denial is overturned, PRC will approve and process the denied claim/referral. Patients will be notified in writing.
2.  If denial is upheld, the patient will be notified in writing.

5.  Patients may appeal the PRC Supervisor decision in writing to the Utilization Review Committee (URC) and be received by the due date listed on the appeal letter, to Oneida Community Health Center, PO Box 365, Attn: PRC Supervisor, Oneida, WI, 54155. URC will meet and review all documentation related to the case and decide to uphold or overturn the PRC supervisor’s decision within 10 business days of receiving the written appeal.

• If denial is overturned, PRC will approve and process the denied claim/referral. Patient will be notified in writing.
• If denial is upheld, the patient will be notified in writing. There is no further appeal of the matter as URC decisions are final.

Direct Care Services

The Oneida Community Health Center can provide many services in-house that do NOT require a referral. Patients must speak with Oneida provider for any orders for services, treatments, supplies that are being requested from outside provider that isn’t specifically listed on PRC referral. For example, some Durable Medical Equipment (DME), bandage and dressing supplies are available for distribution. If these items are not available, a referral will need to be placed for PRC coverage (insurance and Medicare requirements still apply).

Acceptable Documentation for Proof of Residency

All documentation must include name of applicant, physical street address, and be dated within the last 60 days. All documents subject to review that they meet the requirements to prove residency. Please submit original documents, do not include envelopes. Non-pertinent information to the application can be blacked out for confidentiality reasons.

• Official Government Documentation (Tribal, State or Federal Agency)
  • Example: Social Security Administration, Court or Municipalities
• Direct Deposit or payroll stubs
• Utility Bills – Heat, Water, Sewer and Garbage Disposal
• Cable, satellite, phone bills, homeowner/rental insurance statements
• Acceptance letters/grants (high school/college) and dated transcripts
• Current active bank statements and e-statements with dates included
• Notice from homeless shelter will be considered as temporary proof of residency, valid for 60 days only
• Mortgage holder, landlord, rental company on company letterhead
  • Example: Oneida Housing Authority, Oneida Department of Land Management
• Valid government issued identification cards: WI driver’s license or WI state ID card, Tribal ID cards. Must list address used on application to be accepted as proof of residency. No PO Boxes are acceptable.
• Notice from homeless shelter will be valid for one year.

Examples of Unacceptable Forms of Proof of Residency: 

• Personal Mail
• Medical Bills or Health/Dental Insurance Statements
• Personal Checks
• Bulk Mail
• Envelopes
• Hand-written Receipts
• Collection Statements
• Oneida Self-Service
• Vehicle Registration Renewals
• Correspondence from Oneida Comprehensive Health Division

Please note:

• Cellphone pictures of application and/or proof of residency are not acceptable. They tend to be blurry and are not readable when scanned into patient’s account.

**If there is an address discrepancy, additional forms of verification may be requested prior to PRC eligibility approval or payments of claims.

Applications can be dropped off at the Oneida Health Center, emailed to the department email, or faxed to PRC department fax. All this information is at the top of the application and this packet.