10.20.100 Payment Request.
(1) Procedure.
(a) To receive payment from Samish PRC for health services, a person must:
(i) Be enrolled in Samish PRC per STC 10.20.080; and
(ii) Obtain a purchase order from Samish PRC prior to the health visit or procedure (except as provided below for emergency cases).
(b) Samish PRC may only make payment for health care and services:
(i) When the notification requirements below have been met. These notification requirements apply to all categories of eligible individuals;
(ii) When the requirements of 42 CFR 136.61 regarding payor of last resort have been met; and
(iii) After the provider returns the required forms. Once the forms are returned by the provider and are complete, payment is usually made within 30 business days.
(2) Nonemergency Cases.
(a) The PRC enrollee, an individual or agency acting on behalf of the eligible person, or the provider must, prior to providing medical care and services, notify Samish PRC of the need for services and requested services. They must provide all necessary information to determine the medical need for the services and the individual’s eligibility.
(b) Eligible individuals who are referred by a physician to other medical providers (physician, laboratory, radiology, physical therapy, etc.) must notify Samish PRC and request authorization in advance of the visit or procedure.
(3) Emergency Cases.
(a) The PRC enrollee, an individual or agency acting on behalf of the eligible person, or the provider must provide information within 72 hours of the emergency to determine the relative medical need for the service. This must be a life-threatening condition.
(b) The cost of medical care at an emergency facility is three to four times greater than the cost of medical care at nonemergency facilities. Therefore, authorization for service of nonemergency/acutely urgent care at an emergency facility will be reviewed for appropriateness for payment by the Health Director. For appeals, follow procedure in STC 10.20.180. Examples of authorization for Level I emergency care are listed in STC 10.20.140. [Res. 2020-10-013 § 2, 2020.]