PURCHASE REFERRED CARE (PRC)

Welcome to the Cowlitz Tribal PRC Member Education Center

Our goal is to help members understand how the PRC program works and how to stay compliant with program requirements. PRC is not an insurance program. It is a federally funded program with eligibility requirements, medical priorities, and limited resources.

The Cowlitz Indian Tribe’s Purchased/Referred Care Program extends its services to all Cowlitz Tribal Members across an extensive PRC delivery area (PRCDA). In cases where medical services are unavailable at the Siletz Clinic or other IHS facilities, individuals can utilize the Purchased/Referred Care (PRC) program.

Service Delivery Area Map:

WA: Clark, Skamania, Cowlitz, Wahkiakum, Lewis, Thurston, Pierce, King and Kittitas

OR: Columbia

Following PRC requirements helps protect your access to healthcare services and ensures Tribal resources are used responsibly.

What is PRC?

Purchased/Referred Care (PRC) helps eligible Cowlitz tribal members receive healthcare services outside Tribal Health facilities when those services are medically necessary and unavailable within the Tribal healthcare system.

The Purchased/Referred Care (PRC) program covers care that Tribal or IHS facilities can't offer. PRC comes into play when: 

• There's no Tribal or IHS facility within a 30-mile radius of where the patient lives. 
• An IHS or Tribal facility can't provide the emergency or specialized care needed. 
• The patient's other financial resources aren't sufficient to cover the full cost of the required care. 

Am I Eligible?

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To register for the PRC program, each person registering must bring:

• Photo Identification
• Tribal Enrollment or Certificate of Indian Blood
• Proof of Residency: Tribal member must reside within the PRCDA.
  • Exceptions:
    • PRC eligible Members who depart or relocate from the PRCDA will remain eligible for a period not to exceed 90 days from departure.
    • Students eligible for PRC prior to leaving the PRCDA to attend college or university full-time may remain eligible.
• Birth Certificate
  • Marriage/Divorce Papers to Reflect Name Changes from Birth Certificate
• Social Security Card
• Current Insurance Information, if any (Medicaid, Medicare, or Private Insurance)

Member Responsibilities

PRC participant, you are responsible for:

Using Alternate Resources

As per 42 CFR 136.61, the PRC program is obligated to act as the Payer of Last Resort for eligible persons, regardless of any conflicting state or local laws. Members must apply for and use all available health coverage resources, including:

• Medicare
• Medicaid
• Veterans Benefits
• Private Insurance
• State Healthcare Programs

Obtaining Required PRC Prior Authorizations

All services require prior authorization review and approval before care is received.

Reporting Emergency Care

Emergency visits must be reported to the PRC Program within 72 hours of visit.

Responding to Information Requests

Members must provide requested documents and information promptly.

Keeping Contact Information Current

Members must notify the PRC program of any changes and complete an annual registration update.

PRC Referral and Prior Authorization Process

1. Visit your primary care provider.
2. Provider determines medical necessity.
3. Referral is submitted to PRC for review.
4. PRC evaluates eligibility and program requirements.
5. Member receives notification via prior authorization determination.

Emergency Care Rules

Emergency visits must be reported to the PRC Program within 72 hours of visit.

Denial and Appeals 

If the Purchased/Referred Care (PRC) Program is unable to approve payment for a medical service, you will receive a written notice explaining the reason for the denial.

The denial letter will include information about your appeal rights and the steps you can take if you disagree with the decision.

Common Reason for Denials

• Missing Notification Deadlines
• Emergency services not reported within required timeframes.
• No Prior Authorization
• Receiving services without required authorization.
• Outdated Eligibility Information
• Failure to maintain current records.
• Failure to Use Alternate Resources
• Not applying for available insurance or benefits.
• Non-Medically Necessary Services
• Requested services do not meet program criteria.

Contact PRC Staff

Speak with a PRC representative for assistance.

360-575-8275 Option 2; PRC@cowlitz.org 

PO Box 2429, Longview, WA 98632

The PRC Program operates according to applicable federal regulations, Tribal policies, eligibility requirements, and available funding. Coverage is not guaranteed and all requests are subject to program review and approval requirements.