PRC Guide 2024

Purchased/Referred Care

A Reference Guide for PRC Patients

SVT Purchased/Referred Care FAQs

Who? Purchased/Referred Care is provided to all Alaska Natives, American Indians, who reside in the Homer/Seldovia area.

What? Purchased/Referred Care provides preventive medical and dental coverage, OB coverage, routine medical care, labs, x-ray and emergent care.

Why? Seldovia Village Tribe has a federally approved Purchased/Referred Care Service Delivery Area that covers from below the Anchor Point Bridge south including Halibut Cove and Seldovia.

When? Beneficiaries are asked to register for Purchased/Referred Care when completing SVT Health & Wellness registration forms.*

Where? SVT Health & Wellness facilities in Homer or Seldovia.

*Please be sure to bring all documentation showing proof of eligibility: such as Certificate of Indian Blood, Tribal Enrollment Cards, Birth Certificate, and proof of residency. Such as rental agreement, Homer Electric bill, City bill, or Kenai Peninsula Borough Tax bill.

ANNUAL INCOME VERIFICATION

As your Community Health Center, SVT Health & Wellness requires each Purchased/Referred Care patient to provide proof of income annually in order to be in compliance with PRC payor of last resort. The following documentation is accepted as proof of income:

Three (3) months of household paycheck stubs

Most recently completed income tax return or W2 Social Security, Unemployment, disability or pension statements or benefit letters.

Without this information-your unrestricted Health Services at SVT Health & Wellness will become self pay.

Table of Contents

1) Income Verification

2) Pharmacy

3) Emergency Room Use

3) Nurse Hotline

3) Denial Process

4) Alternate Resources

4) Road Travel

4) Proof of Insurance

4) Wellness Services

5) Referrals to ANMC & Private Sector, OB Care

5) Dental Services

6) Patient Responsibilities

Whenever possible, medications prescribed for you at SVT Health & Wellness will be dispensed from our Pick Point machines on site or ordered from Alaska Native Medical Center’s Village Pharmacy. Medications from either of these are provided at no cost to you.

If the prescribed medication is not available at SVT Health & Wellness facilities or you need this medication urgently, a provider will write a prescription for up to 10 days medication. This urgent prescription can only be filled at Ulmer’s

Pharmacy in Homer. Prescriptions needed for longer than 10 days and are not filled as stated become the patient’s responsibility and are self pay.

Purchased/Referred Care Does not Cover:

Sleeping medication, all non-urgent and chronic medications. These MUST be ordered from ANMC Village Pharmacy.

All over-the-counter medications such as

Ibuprofen, Claritin, Prilosec, and Naprosyn.

Controlled medications, except for acute injury or condition only, up to a 10 day onetime supply.

Purchased/Referred Care is a payer of last resort, all other forms of coverage must be exhausted first. Be sure to notify at the time of visit of other primary coverage such as Medicare, Medicaid, Denali Care, or private insurance.

RE ORDERING MEDICATIONS FROM VILLAGE PHARMACY

When your provider has prescribed medications that require monthly refills from Alaska Native Medical Center Village Pharmacy, it is your responsibility to re-order these medications monthly.

Here is how:

1. Reorder when you have 10 days of medication remaining.

2. Call toll free 1-877-365-1104

3. Be prepared to leave the following information.

a. Your full name

b. Date of birth

c. Your RX number and phone number

d. Name of medication you are requesting to be refilled.

Medications will be refilled and mailed to the address you requested.

Please note: You will need to leave a message on the answering machine and you will not be speaking with a pharmacist.

If you have not received your medication within 7 days you will need to call 1-877-365-1104 and leave a message stating medication hasn’t been received.

Purchased/Referred Care will pay for true ‘life and limb’ emergencies. For example loss of consciousness, chest pain, stroke symptoms or respiratory distress.

We ask that you use your best judgement. If you are ill during the day, call SVT Health & Wellness and come in for a visit. Evenings call SVT Health & Wellness nurse hotline, don’t wait until a crisis develops. Conditions such as a recurrent migraine, earache, toothache, flu or cold don’t warrant a trip to

the ER and your request for coverage will be denied. Unfortunately, we don’t have the funding to cover emergency room visits for non-emergencies.

- Nurse Hotline -

Before going to the Emergency Room call SVT Health & Wellness Nurse Hotline at 226-2228 x1.

Emergency care is defined as an acute medical condition, sudden in onset with severe symptoms posing an immediate threat to life, limb, or organ. An emergency requires immediate treatment by a physician.

Medical conditions in which a delay in care would be hazardous to life or would result in serious complications are also considered.

WHAT TO DO WHEN RECEIVING A DENIAL LETTER

Seldovia Village Tribe Purchased/Referred Care has limited funding to provide services to you our beneficiaries. It is important that you understand what is covered with this funding and what is not. The requirements are from the Federal Government through Indian Health Services it is the law.

Any request for reconsideration or appeal must be in writing within thirty (30) days from the date denial letter is received.

When a denial letter is received here are your options for an appeal.

1. Read denial letter in its entirety.

2. If the service performed at South Peninsula Hospital was not a referral from SVT Health & Wellness the bill will automatically be self pay.

3. Non-Emergencies treatable at SVT Health & Wellness will be self pay.

4. By law Seldovia Village Tribe Purchase/ Referred Care funds are the payer of last resort. You must apply for all alternate resources available. (see page 4)

You may request a reconsideration or an appeal to denials by sending additional information not already submitted to SVT at the following address:

Seldovia Village Tribe

Purchased/Referred Care

P.O. Drawer L

Seldovia, Alaska 99663

Fax: 907-234-7865

Email: tgallien@svt.org

ALTERNATE RESOURCES

All beneficiaries MUST sign up for alternate resources

As specified in Title 42 CFR § 136.61 of Indian Health Service Manual, the IHS will no longer pay an AI/AN patient’s medical bills under protest because the patient refused to apply for alternate resources.

These include: Medicare, Medicaid, VA Health Services, employer provided group health insurance and the SVT Health & Wellness Sliding Fee Scale.

An appointment can be made with our Outreach and Enrollment department at our Homer facility, or with our Community Health Representative at our Seldovia office.

PROOF OF INSURANCE

Beneficiaries with private insurance, medicaid, medicare, must provide a copy of health coverage when visiting SVT Health & Wellness. Without this information your unrestricted Health Services at the SVT Health & Wellness will become self pay.

Contract Health by Federal Law is a payor of last resort and all other resources must be exhausted first.

ROAD TRAVEL REIMBURSEMENT

SVT Beneficiaries are eligible for road travel reimbursement when referred from SVT Health & Wellness for treatment at the Alaska Native Medical Center (ANMC).

Ask our referral department for this form when a referral to ANMC is prescribed.

Travel reimbursement forms must be signed by SVT Health & Wellness referral department before travel to appointment. While at ANMC patient must have the nurse or doctor sign-off on the form proving the patient attended their appointment. Travel reimbursement forms need to be returned to SVT Health & Wellness no later than 10 days after appointment to be considered for payment.

Payments are sent out every three months February, May, August, and November.

WELLNESS SERVICES COVERED UNDER SVT PURCHASED/REFERRED CARE:

• Visits to our Integrative Medicine provider

• Integrative labs

• CommunityAcupuncture

• Massage when referred by SVTHW provider

• Nutritional IV’s

• Behavioral Health

“We strive at incorporating whole body, mind and spirit towards welness and healing by looking at the whole person.”

Crystal Collier President/CEO

It is ALWAYS your choice where you receive treatment, but you must be aware of and understand that any referrals outside of the guidelines of this policy will result in you being outside of the umbrella of coverage by either Seldovia Village Tribe or ANMC. In such cases, you will personally be responsible for medical costs incurred.

REFERRALS TO ALASKA NATIVE MEDICAL CENTER & PRIVATE SECTOR

Referrals for SVT PRC patients to be made to Alaska Native Medical Center (ANMC). There are some exceptions to this policy that will allow for consultation in Homer. (No consultations are allowed to providers outside of Homer, such as Soldotna, other than to Alaska Native Medical Center.)

Referrals may be made to local (Homer) providers for consultation and recommendations for SVT PRC patients.

DENTAL SERVICES

• D0120 Periodic Oral Eval

Diagnostic Radiology may refer to South Peninsula Hospital for basic X-ray, Ultra Sound, screening mammogram and/or diagnosticmammogram (not including a biopsy).

No Referrals: For CT, MRI or Procedures (eg: colonoscopy) at South Peninsula Hospital or with any local provider. (Must be referred to ANMC)

Pre-natal care: SVTHW will provide pre-natal care to all pregnant Native patients who want to deliver at ANMC.

SVTHW Providers would conduct the majority of pre-

natal visits and coordinate care with Anchorage Service Unit Maternal Child Health Coordinator.

SVTHW may refer to Homer provider of choice if pregnancy is not high risk. (A SVT beneficiary must apply for Denali Care and if denied must give a copy of denial letter to SVT.)

SVT does not pay for drug/alcohol or mental health referrals.

The following are a few procedures covered by Purchase/Referred Care:

• D2161 Amalgam 4+ surface

• D0140 Limited Eval-Problem Focus

• D0150 Comprehensive Eval

• D0180 Comprehensive Perio Eval

• D0210 Full Mouth Xray

• D0220 Periapical first film

• D0230 Periapical ea additional film

• D0240 Intraoral Occlusal Film

• D0270 Bitewings Single Film

• D0272 Bitewings 2 Films

• D0274 Bitewings 4 Films

• D0277 Vertical Bitewings 7+ Films

• D0330 Panoramic Film

• D1110 Adult Prophy

• D1120 Child Prophy

• D1206 Flouride/Child

• D1208 Flouride/Adult

• D1351 Sealent/Per Tooth

• D2140 Amalgam 1 surface

• D2150 Amalgam 2 surface

• D2160 Amalgam 3 surface

• D2330 Resin 1 surface anterior

• D2331 Resin 2 surface anterior

• D2332 Resin 3 surface anterior

• D2335 Resin 4+ surface anterior

• D2391 Resin 1 surface posterior

• D2392 Resin 2 surface posterior

• D2393 Resin 3 surface posterior

• D2394 Resin 4+ surface posterior

• D3221 Pulpal debridement primary and perm

• D7111 Extract coronal remnants

• D7140 Extraction

• D7210 Surgical Extract/erupted

• D7220 Surgical Ext/impact/soft

• D7230 Surgical Ext/impact/part bony

• D7250 Surgical Ext/impact/full bony

• D9310 Consultation

• D9430 Office Visit/Observation

• D9440 Emergency office visit

HOURS OF OPERATION

Homer

Health Wing Hours:

Monday: 9:00 a.m. to 7:00 p.m.

Tuesday: 9:00 a.m. to 7:00 p.m.

Wednesday: 11:00 a.m. to 7:00 p.m.

Thursday: 9:00 a.m. to 7:00 p.m.

Friday: 9:00 a.m. to 7:00 p.m.

Wellness Wing Hours:

Monday: 9:00 a.m. to 5:00 p.m.

Tuesday: 9:00 a.m. to 5:00 p.m.

Wednesday: 11:00 a.m. to 5:00 p.m.

Thursday: 9:00 a.m. to 5:00 p.m.

Friday: 9:00 a.m. to 5:00 p.m.

Dental Hours:

Monday: 8:00 a.m. to 6:00 p.m.

Tuesday: 8:00 a.m. to 6:00 p.m.

Wednesday: 10:00 a.m. to 6:00 p.m.

Thursday: 8:00 a.m. to 6:00 p.m.

Seldovia

Monday: 9:00 a.m. to 5:00 p.m.

Tuesday: 9:00 a.m. to 5:00 p.m.

Wednesday: 9:00 a.m. to 5:00 p.m.

Thursday: 9:00 a.m. to 5:00 p.m.

Friday: 9:00 a.m. to 5:00 p.m.

~Homer~

To make an appointment or have questions regarding services please call (907) 226-2228.

~Seldovia~

To make an appointment or have questions regarding services please call (907) 435-3262.

- Our Patients’ Responsibilities -

• Arrive on time for appointments.

• Keep all scheduled appointments or call at least 24 hours in advance to reschedule or cancel appointments. Call 226-2228 to make any appointment changes.

• Provide accurate and complete information regarding your health status.

• Share in health care decision-making and participate in the development of a mutually agreed upon treatment plan with your health care provider.

• Maintain as healthy a lifestyle as possible and follow through with a treatment plan you agree with.

• Treat other patients and staff with respect and courtesy.

• Ask questions about anything you do not understand.

• Let us know how we’re doing by filling out a patient satisfaction survey.

• Provide up-to-date contact information including the best way to reach you