Purchased/Referred Care (PRC)
Purchase Referred Care
PRC Hotline (for all appointments)
Stella Chippewa and Mary Jo McSauby, Monica Anderson
*Please stop in and pick up your new PRC cards to avoid interruption of your PRC benefits*
The Purchased Referred Care (PRC) office serves clients in Grand Traverse, Charlevoix, Leelanau, Benzie, Manistee, and Antrim Counties. The program relies upon federal and RAO funds.
Priority Levels of care are established at the beginning of each fiscal year, in order to provide that funds will be available for the services most needed by membership. As funds are depleted, the priority level for services available under PRC will be adjusted to ensure that essential services are available. The current priority levels will be
posted in all GTB offices and will be circulated via the GTB newsletter. Persons requesting services outside of the current priority level will be placed on a DEFERRED SERVICES list. When funding for those services become available again, persons on the deferred list will be notified and given priority for those services.
**Descriptions of the dental and medical priority levels are available
upon request. **
Purchased Referred Care operates on a pre-approval basis, and pre-approval requirements.
Pre-approval is required at least 48 hours (2 days) prior to obtaining all medical/dental/optical/laboratory services. This information is needed to process the paperwork for claim payment, authorizing payment for service. Actions outside of this procedure may be subject to payment denial.
For emergency services, a PRC specialist must be notified within 72 hours of incident by the participant. All emergency cases are subject to review, prior to final payment authorization.
If notification procedure is not followed or if upon review a service fails to meet eligibility emergency criteria, the bill for the service may be subject to payment denial.
If you need emergency services, you must notify this office within 72 hours after the service. Emergency services are for life threatening situations only, as determined by the doctor’s report. Elders have up to 30 days to notify the CHS office. All emergent services are reviewed before authorization is issued.
You MUST send PRC updated information to avoid suspension of medical benefits if:
Change in name
Change in phone/contact information
Change in medical coverage(s)
YOUR MEDICAL INFORMATION CANNOT BE DISCUSSED WITH ANYONE WITHOUT YOUR WRITTEN CONSENT. Please keep your consent form updated yearly if you depend on someone to manage your medical affairs.
IF YOU HAVE ANY CONCERNS OR QUESTIONS ABOUT YOUR ELIGIBILITY OR YOUR MEDICAL BILLS, Please CONTACT PRC IMMEDIATELY.
We know how confusing medical, dental, etc. can be. Our goal is to make sure all your questions are answered and any concerns resolved. When you have questions or concerns about any of your medical, dental, optical, RX, or Behavioral Health bills, please call PRC immediately.
If a PRC participant is denied payment for service, the participant will be notified in writing stating the service was denied and the reason(s) for denial. The participant has the right to appeal the decision, in writing. If an appeal is not initiated within 30 days allowed from the issue of the denial, appeal may be denied.
**Note: Bills incurred prior to meeting eligibility for the PRC program, or when suspended from service WILL NOT be paid.
APPEAL PROCESS (SUMMARY)
If you would like to appeal a decision regarding payment of your medical, dental, RX, optical bill(s) you may follow the GTB Due Process. The first step is to contact the Division IV Manager at (231) 231-534-7477 to request a reconsideration of the PRC decision. The Department Manager will review your case and make a determination about payment of your bill.
The purpose of estimates and treatment plans are to minimize unexpected charges and unauthorized services. If a provider advises that a procedure is required (e.g. dental work, elective surgery, etc.) a treatment plan describing what is to be done, along with cost estimates, are required by PRC office for review. If, upon review, the treatment plan is acceptable, then approval will be granted and a purchase order is issued. Additional documentation or explanation of necessity may be required for this review. If this procedure is not followed, the bill(s) for that service may be denied for payment.
Maximum $1,000. Per year for members under 55.
Maximum $5,000. Per year for members 55+