Are Indian descendents eligible for PRC if they reside on a reservation?
Yes. See 42 CFR 136.23 and 136.12.
Are Indian descendents not eligible for PRC off the reservation?
Indian descendents residing off the reservation may be eligible if they meet certain conditions. Pursuant to 42 CFR 136.23 (a) (2) (i) and (ii), if not residing on the reservation such individuals must live within the PRCDA 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.” Also see 42 CFR 136.23 (b) related to students and transients, and 42 CFR 136.23 (d) for foster children placed off the reservation.
If 136.12 is mentioned in 136.23, does this mean Indians eligible for direct care are also automatically eligible for PRC?
No. In order to receive PRC, Indian beneficiaries must also meet the PRC eligibility requirements of 42 CFR 136.23, 136.24 and 136.61.
Why do I have to apply for Alternate Resources?
This is required by 42 CFR 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. IHS/Tribal facilities are considered resources. Payer of last resort means an entity that pays after all other programs have been pursued for enrollment and payment.
If I am eligible for PRC, why are some of my medical bills being paid and others not?
Each visit to a non-IHS health care provider and the associated medical bill is distinct and must be examined individually to determine PRC eligibility. All PRC requirements must be met for each episode (treatment) of care. A patient must meet residency, notification, medical priority of care and use of alternate resources requirements of 42 CFR 136.23, 136.24 and 136.61 in order to be eligible for PRC.
Example: If a PRC authorization is issued, IHS will pay the first medical treatment. Follow-up care or additional medical care are to be done nearest accessible IHS or tribal facility; or will require approval with a new PRC authorization. If this process is not followed, the patient may be responsible for the expense.
