Referrals for services outside of PRHS must be issued by a
PRHS must be issued by a PRHS provider. Pharmacy prescriptions will be issued by
PRHS with Levels of Care I & II. PRHS does not cover over the counter, (OTC)
prescriptions. The CHS program must be notified within 72 hours for all hospital
emergencies. If you are elderly or disabled and are (65) years or older, you
must notify the CHS program within (30) days. PRHS requests all patients
schedule a follow-up appointment with PRHS following the emergency for
continuity of care. Once the referral is issued by PRHS-CHS, any and all
follow-up appointments scheduled by the referring Provider/Hospital must be seen
by PRHS Provider for any additional referrals.
The CHS program adherers to the IHS Payor or last resort rule and patients must apply for other payment resources. PRHS will assist patients upon request, in seeking alternate resources. Alternate resources include Medi-Cal, CMSP, Medicare, Private Insurance, Healthy Families, and other resources. The CHS Committee is established to review all deferred referrals which cannot be paid for within the funded Level of Care. Level of medical need is determined and used as a basis for all CHS denials. CHS will issue the denial notice which includes the appeal process and time frame to seek and appeal.
If you are issued a Referral Authorization and meet all eligibility guidelines, CHS issues a Purchase Order for payment of services. The CHS funds are limited and can not meet all the needs of the community; therefore, referrals do not bind CHS to payment for services. The patient is responsible for submitting all billing statement, EOBís and other billing documents to CHS prior to issuing a Purchase Order for payment. Any patient who obtains Medical and Dental services, or prescriptions, without prior authorization or knowledge, will be denied by CHS, unless it is a notified emergency.
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