Purchased/Referred Care (PRC) provides payment for medical, dental, optical, pharmacy, and mental health services for eligible Grand Ronde Tribal Members that reside within the six county service area. All patients that do not have an alternate resource and are going to be hospitalized (Inpatient Hospital Stays) must apply for the Oregon Health Plan (elective surgeries, emergency services). Refusal to apply for alternate sources will result in denial of payment. When patients receive checks for payment or partial payment of medical or dental bills and do not apply the entire amount to the bill, PRC will not be responsible for that bill. It will be the patient’s responsibility for payment. Enrolled members or minor dependents of an enrolled member of the Confederated Tribes of Grand Ronde who reside within our established service delivery area are eligible for services. The established service delivery area includes the counties of Washington, Yamhill, Polk, Multnomah, Marion, and Tillamook. All services must be preauthorized by the Purchased/Referred Care Program based on medical priority.
Dental care is limited to $1,000 of approved dental care per patient, per calendar year. Remember to call and receive a preauthorization for dental appointments. Make your dental provider aware of any other insurance that you may have that will assist with dental costs. If a procedure cannot be paid for, it will be placed on a Deferred Services list. Patients will receive a letter of confirmation when placed on the list. Patients will be notified when funds are available. PRC operates under a Priority III basis. Services not deemed Priority III will be added to the Deferred List at the patient’s request.
PRIORITY I: Urgent and emergent care that must be done within 30 days to preserve life, limb, function or senses.
PRIORITY II: Non-emergent care that is needed within 30-60 days, but enough time during which alternate resources can be evaluated.
PRIORITY III: Elective care that can be safely deferred for more than 60 days.
PRIORITY IV: Luxury procedures such as cosmetic surgery.
The priorities are determined by Indian Health’s Operational Procedures. The interpretation of the priorities for our tribal health program is determined by consultation with professional health care providers at the Grand Ronde Health & Wellness Center (GRH&WC)
Keep your Insurance. If you have health insurance we can pay for your deductible and any balances after the insurance company pays — assuming you meet all requirements of our PRC program. For those who have insurance, all correspondence from insurance stating what they have paid or denied must be sent to us within 60 days (private insurance, Medicare, etc.) If you fail to comply with the requirements of your primary insurance, PRC may deny payment. We pay only after all alternate resources have responded.
Your responsibilities are: you need to phone in appointments 3 to 7 days in advance for preauthorization and to receive a confirmation number even if you have insurance, Medicare, Medicaid, Private, etc. Inform doctors of private insurance, Medicare, or Oregon Health Plan or other alternate resources that cover medical or dental services. Mail PRC all pre-authorized bills, insurance explanation of benefits. All patients receiving elective surgery must receive PRIOR APPROVAL from a doctor at GRH&WC. These services will be rendered upon availability of funds. If you reside within 25 miles of the GRH&WC or the Chemawa Health Center, you will need to receive medical and dental services from one of these facilities. If you are in need of a referral to a specialist, the referral must come from a Medical or Dental Provider in one of these clinics. PRC is only able to pay for Priority III levels of service outside of these facilities and proper use of your alternate resource is also necessary. Every appointment must be called into PRC three to seven (3-7) days prior to receiving services (emergency room services require that PRC be notified no later than 72 hours after being seen. Emergency room services will be reviewed by the Clinic provider to determine the priority level of the service). Confirmation numbers will be given for all preauthorized appointments.
The Purchased/Referred Care program is federally funded under P.L.93-638 by Congress for the Grand Ronde Tribe. To receive services through this program, one must meet the Purchased/Referred Care Service eligibility requirements outlined above. All routine medical care, including follow-up visits, must have prior approval.
The Notice of Privacy Practices for the Grand Ronde Health & Wellness Center is available to you by following this link: Click Here