Patient Referred Care

What is a PRC?:

Patient Referred Care (PRC) is a program funded under CBN Health Care, Inc. Department of Health and Human Services that covers contract quality health/medical care. Qualified individuals are provided assistance with health care, thus ensuring financial coverage for health care costs.

General Information:

Purchased/Referred Care (PRC) is not an entitlement program or an insurance program. The PRC Program may or may not pay for services provided  at a private hospital, a private doctor’s office, or any other health care facility away from the CBN Health Center.  Generally speaking, the PRC program will pay for medical/dental care services which are not available through a local Tribal health center or I.H.S. facility, or for qualified medical/dental emergencies.  If the CBN Health Center should issue you a medical/dental referral for care it does imply that the PRC Program will be paying for the services.

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5 PRC Consideration Factors
  • Indian Decent:

    • Any registered member of the Canoncito Band of Navajos

    • Are you married to Canoncito Band of Navajos member with a legally binding marriage certificate?

  • Residency for a registered member of CBN:

    • Reside within the Canoncito Band of Navajos service unit Purchased/Referred Care Delivery Area.

    • Do not reside on the reservation but reside within a CHSDA and member of a Canoncito Band of Navajos

    • CHSDA includes the following counties: Bernalillo, Cibola, and Sandoval.

    • Full time student at a college or trade schools, including normal school breaks. (12 credit hours or more). A completed student health form signed by school official is required for verification. 

  • Alternative Resource like Medicaid or Medicare:

    • The use of alternate resource is requited to be used before PRC dollars when such resources are available and accessible to the individual.

    • An individual must apply for and use all alternative resources available such as Medicare, Medicaid, private insurance, Sate and Federal programs and use of I.H.S. and Tribal health facilities prior to being allowed access to PRC funds.

  • Notification:

    • In emergency cases, you must notify Canoncito Band of Navajos health center within 72 hours of the hospital admission and/or outpatient visit by calling and speaking with any of the Purchased Referred Care staff.

    • A faxed notification from the hospital/ER is also allowed

    • Special consideration is given to Elders (age over 65). They will have 30 days to provide notification

  • Medical Priority:

    • Care and treatment for health care services will be determined based of relative medical need or considered within the CBNHC medical necessity. Limited to prevent the immediate threat to life, limb or senses.

    • You must obtain prior approval from the Canoncito Band of Navajos health center’s Purchased/Referred Care for NON-Emergency care.

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Office Hours:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

8:00am – 4:30pm

8:00am – 4:30pm

8:00am – 4:30pm

12:30am – 4:30pm

8:00am – 4:30pm

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PRC

Wendi Abeita

 

Main: 505-908-2307 ext. 108

Fax: 505-908-2303

Appeals & Reconsiderations
  • An individual may request for reconsideration of the initial denial with supporting information not previously submitted to the CBNHC PRC team.

  • An individual may appeal the original CHS denial within 30 days receipt of a denial letter to the 1st level appeal which is the referring facility. If affirmed , the individual may appeal to the chief operations officer as 2nd level of appeal within 30 days of receipt of the  affirmed denial; the last appeal stage is with CBNHC management  where a final decision is made without recourse.

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