Purchased/Referred Care: Eligibility

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For Pokagon Band citizens whose needs require a referral for medical services outside the Pokagon Health Services, certain criteria must be present for them to be eligible for Purchased/Referred Care funding to help pay for those services.

Each patient must update their registration annually during their birthday month. Patients who are updating their eligibility will be given until the last day of their birthday month. If your file is not up-to-date by the last day of your birthday month, your file will transfer to Clinic services only, and you will not be eligible for Purchased/Referred Care until your file is complete and up-to-date.

We will be unable to make PRC payments on your behalf unless your Patient Registration is complete, accurate, and up-to-date on the date of services. Unless the file is updated, health care bills and prescription will not be paid by PRC.

The following must be on file with Health Services before you are PRC eligible:

  • Establishing Care visit with PHS Provider within the last 3 years
  • PRC Agreement signed and on file with PHS
  • Proof of Tribal Affiliation:
    • A copy of your Tribal Enrollment card or a letter of Enrollment (front & back of the card)
    • Proof of Guardianship/Custody/Power of Attorney documents when applicable
  • Proof of Address:
    • A copy (front & back) of your Michigan/Indiana Drivers License or a copy of a Michigan/Indiana Picture Identification Card showing your current address. Citizens under the age of 18 must have a copy of their Guardian's Driver's license or State ID
    • If you do not have a Driver's License or a State ID we will need one (1) piece of mail with your current address. Tribal and personal mail is not valid.
  • A copy of your insurance card or Medicaid card (front & back) or a written Declaration of an ultimate denial from an alternate resource for payment, such as health/medical insurance, State Medicaid, Federal or other assistance programs
    • Medical insurance or Medicaid denial must state why coverage has ended or was denied and cannot be for failure to submit documentation.
    • Proof of that Employer Sponsored Health Insurance is not affordable based on the definition provided by Healthcare.gov

There are other criteria for children under the age of 18, pregnant women, and patients of behavioral health or dental which may qualify them for full or partial PRC services. Please contact the PRC Team at (269) 462-4401 to discover for what benefits you could be eligible.

Notification Requirements

Non-Emergency Cases

  • The patient shall notify the Referral Specialist or the PHS Provider prior to provision of medical services.
  • Once a referral order is generated for medical services, patients/specialists must provide notification of appointment dates prior to services.

Emergency Cases

  • The patient/patient representative/medical provider shall notify PHS within 72 hours after the initial admission/start of treatment.
  • If the patient is 65 years or older or disabled, notification is required within 30 days.
  • The patient must make every attempt to use the PHS clinic prior to resorting to walk-in or ER facilities. Using the ER is a last resort and only for cases that are a potential threat to life or limb.

If notification is not received, PRC funds cannot be used to cover the cost of medical care.

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