The PRC Program operates under federal guidelines. In order to be eligible, you must document:
Santo Domingo members who have other forms of insurance such as Medicare, Medicaid etc., please be advised other forms of insurance will be billed first. Any remaining charges for an approved service will be paid for by the PRC Program.
Q. Why are Santo Domingo Pueblo descendants not eligible for PRC off the reservation?
Santo Domingo Pueblo descendants residing off the reservation may be eligible if they meet certain conditions. Pursuant to 42 C.F.R. 136.23 (a)(2)(i) and (ii), if not residing on the reservation such individuals must live within the CHSDA and (1) be members of the tribe(s) located on the associated reservation or (2) "maintain close economic and social ties with that tribe or tribes."
Referrals are not a guarantee of payment. A referral is a recommendation for treatment or tests only. The PRC program must review the referral to make the determination for PRC approval of payment. PRC eligibility requirements must also be met.
This is examined on a case-by-case basis because charity programs vary in their coverage of care, funding for care, and requirements for eligibility.
No. Currently there is no requirement for patients to apply for an Alternate Resource when receiving direct care.Q.Why do I have to apply for Alternate Resources?
This is required by 42 C.F.R. 136.61, Payor of last resort. Approval of PRC payment for services is considered after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to apply for the alternate resource.Q. If we are guaranteed health care from our treaties as long as the water flows and the grass grows, why are Indians required to apply for AR?
It is required under 42 CFR 136.61, Payor of last resort. While some treaties mention health care, the Indian Health Service is not an entitlement program, and therefore funding for PRC is not guaranteed by the Federal government. AR allow PRC funds to be conserved, thereby providing health care for more Indian beneficiaries.Q. If I am residing in an area where there is a federally recognized tribe, but no reservation, can Social, Economic Ties be automatic to that tribe or do I have to apply/petition?
No. Social and economic ties are not automatic. The individual has to apply to the Tribe.Q. Can the 180-day rule be extended?
No. 42 C.F.R. 136.23(b)(1) and (c) clearly state the period is "not to exceed 180 days." A patient receiving PRC authorized services prior to the 180 day deadline is extended.Q. If a student is covered under PRC, are the student’s dependents also covered?
Yes, dependents may be covered for PRC up to 180 days if they were eligible for PRC at their original (home) CHSDA.Q. If I move from one federally recognized reservation to another federally recognized reservation, does the 180-day rule apply?
The 180-day rule applies until the client establishes residency and becomes eligible in another CHSDA.Q. Can Non-Indians be eligible for PRC?
Yes, but only for three classes of non-Indians. These include (1) non-Indian women pregnant with an eligible Indian's child during pregnancy through postpartum (2) non-Indians under 19 who are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian and (3) non-Indian spouses of eligible Indians if all such spouses are made eligible through a tribal resolution.Q. What does Social, Economic Ties mean?
Close social and economic ties are determined by the governing body, or designee, of the local Tribe. A letter from the Santo Domingo Tribal office must be in place and submitted on behalf of the tribal member for PRC services.Q. Can a PRC Program establish a cap on certain procedures, such as dental procedures, eyeglasses, etc.?
No. If a health service is within medical priorities PRC must pay for the full amount of the service.Q. Can a CEO or Tribal Health Director determine Social, Economic Ties, or is this strictly a Tribal function?
This is a tribal function. However, this determination can be delegated by the relevant Tribe(s) to the CEO or Tribal Health Director.
Purchased / Referred Care (PRC), formerly called Contract Health Services, assists Santo Domingo tribal members to pay for specialty medical, dental and mental health care services that are not available at the Santo Domingo Health Center, and for emergency care.
All Purchased / Referred Care must be approved in advance.