IHS Purchased/Referred Care Pays for Outside Care Only When Funds Are Available, Ranked by Medical Priority, as Payer of Last Resort
The Fact
When an IHS or tribal clinic can't provide a service, it can refer the patient out through Purchased/Referred Care (PRC). IHS states that payment for outside care 'can only be authorized by a PRC official if funds are available,' that 'a referral does not constitute authorization for payment,' and that requests are 'ranked according to relative medical priority.' The top tier (Priority 1, 'Essential Services') covers care 'necessary to protect life, limb, or vision in the next 30 days.' PRC is also 'the payer of last resort' — other coverage such as Medicare, Medicaid or private insurance must be used first.
What This Means
A doctor can say you need a specialist and the referral can still be deferred or denied because the money ran out. Care that isn't about saving a life, limb or eyesight in the next month waits in line behind care that is.
Why It Matters
When the year's PRC money runs low, anything below the top priority can be deferred until new funds arrive. That's a budget rule, not a medical judgment about the patient.
Key Terms
Payer of last resort: The program that pays only after every other insurance or coverage has paid or said no.
Sources
Indian Health Service, Oklahoma City Area. "Purchased/Referred Care Information." https://www.ihs.gov/sites/oklahomacity/assets/File/Purchased%20Referred%20Care%20Information%20Page.pdf
Indian Health Service. "PRC Medical Priorities." https://www.ihs.gov/sites/prc/themes/responsive2017/display_objects/documents/PRC_Medical_Priorities.pdf
Indian Health Manual, Part 2, Chapter 3: Purchased/Referred Care. https://www.ihs.gov/ihm/pc/part-2/chapter-3-purchased-referred-care/