08/21/2026
📣 HEALTH EDUCATION: Understanding IHS Purchased/Referred Care (PRC)
Did you know that some medical services are not available at every IHS facility? When the care you need cannot be provided through IHS, you may need to be referred to a non-IHS specialist or facility.
Specialty care may include but are not limited to:
🩺 Endocrinology – diabetes and hormone care
❤️ Cardiology – heart care
🦶 Podiatry – foot and ankle care
Other specialty services depending on your medical needs
🩺 Start With Your Primary Care Provider (P*P)
Many specialty services require a referral from your Primary Care Provider (P*P). Your P*P is the provider you see regularly who helps manage your overall health and coordinates specialty care when needed.
If you do not have a P*P, please reach out to the THIP Office. We can help you establish one!
Having a P*P is extremely important. They can help manage chronic conditions, order testing, make specialty referrals, review medications, and help you navigate the healthcare system.
What is Purchased/Referred Care (PRC)?
When medically necessary care is not available through an IHS or Tribal facility, your healthcare provider may refer you to an outside provider or facility. When authorized, payment for that care may be made through the IHS Purchased/Referred Care (PRC) Program.
⚠️ IMPORTANT: A referral does NOT automatically mean IHS/PRC will pay for the appointment or services.
PRC is not an insurance or entitlement program. PRC determines whether the patient and requested services meet eligibility, notification, medical priority, alternate-resource, and other requirements before authorizing payment.
Your Responsibilities as a Patient
Help protect yourself from unexpected medical bills by staying involved in the process:
✅ Keep your IHS and PRC information current.
✅ Establish and maintain a relationship with a P*P.
✅ Make sure required referrals and PRC authorizations are completed before non-emergency specialty care whenever applicable.
✅ Ask whether your referral has been authorized for payment—don't assume the referral itself is authorization.
✅ Provide PRC with requested eligibility or insurance information.
✅ Use other available healthcare coverage, such as Medicaid, Medicare, VA benefits, or private insurance, when applicable. PRC generally serves as the payer of last resort.
✅ Keep copies of referrals, authorization information, bills, letters, and other paperwork.
✅ Before follow-up visits or additional services, verify whether another authorization is required. An authorization for one episode of care may not automatically cover future care.
✅ If you receive a bill for care you believe was authorized through PRC, do not ignore it. Contact PRC and/or your care coordinator as soon as possible.
🚨 Emergency care has specific PRC notification requirements. If you receive emergency treatment outside an IHS/Tribal facility, contact the appropriate PRC office as soon as possible so they can determine whether PRC requirements have been met.
❌ What Happens if PRC Denies Payment?
If PRC denies your request or payment, you should receive a written denial explaining the reason(s). For IHS-administered PRC programs, patients generally have the right to request reconsideration or appeal the decision. The denial notice should explain where to submit the request and the applicable deadline. Under the IHS process, the first reconsideration/appeal generally must be submitted in writing within 30 days of receiving the denial notice.
Do not throw your denial letter away! Bring it to the THIP Office if you need help understanding what it means or gathering documentation for the next step.
What if I Have Medicaid?
If you are a Montana Medicaid recipient, the payment process may look different because Medicaid is an alternate healthcare resource and may provide coverage for services outside IHS. PRC generally considers available alternate resources before PRC funds are used.
If you are unsure what services your Medicaid benefits cover, reach out to the THIP Office and we can help you navigate your benefits and coordinate your care.
Don't have Medicaid but think you may qualify? Come see us! We can help connect you with resources to begin the application process.
💙 You don't have to navigate the healthcare system alone.
Our goal at Crow Tribal Health Improvement Program (THIP) is to help reduce barriers to care, connect you with resources, and help you understand the steps needed to access the healthcare services you need.
Have questions about P*Ps, referrals, Medicaid, specialty care, or care coordination? Stop by or contact the THIP Office—we're here to help!
