Services

Primary Care

If you need primary care services from a provider that is not part of the Indian Health Service (IHS), Tribal, or Urban (ITU) health system, you must get prior authorization before receiving those services.
If you live within 25 miles of an IHS/Tribal/Urban (ITU) facility, you are generally required to use that ITU facility first for primary care services rather than going directly to a non-ITU provider.
If you go to a non-ITU primary care provider without the required prior authorization, the service may not be covered.

Specialty Care

A patient cannot schedule a specialist appointment on their own and expect it to be covered through PRC (Purchased/Referred Care).
The patient must first be evaluated by a Ponca Health Service/ITU provider, who determines that a specialist is needed based on medical necessity.
The Ponca Health Service/ITU provider must send a written referral and any relevant medical information to PRC before the specialist visit is scheduled.
PRC will review the request and either approve or deny it before the appointment can move forward.

Vision Services

Coverage details and limitations are described in the PRC Eye Care Plan.

Download Eye Care Plan PDF Download

Dental Services

Coverage details and limitations are described in the PRC Dental Service Plan.

Download Dental Service Plan PDF Download

In emergency cases, a sick or disabled member — or an individual or agency acting on behalf of the member — shall, within 72 hours after the beginning of treatment, notify PRC of the service and submit information necessary to determine the relative medical need for the services and eligibility of the individual.

Section 406 of P.L. allows the elderly and disabled 30 days to notify PRC of the emergency medical care received.

Definition of an emergency: any medical condition for which immediate medical attention is necessary to prevent the death or serious impairment of the health of an individual.

All alternate resources must be exhausted. PRC is a payer of last resort. When a patient has Medicare, Medicaid, Veteran’s benefits, private insurance, worker’s compensation, or any other resource, that resource is the primary carrier. Patients must immediately provide all explanations of benefits from the primary carrier(s) to the PRC office when received by the patient.