10.20.120 Payment Restrictions.
(1) Samish PRC authorizes medical care mostly upon request but does operate within certain levels of care as described in STC 10.20.140.
(2) Samish PRC may only pay for medical care that is delivered by one of the following licensed providers:
(a) Medical doctor or doctor of osteopathy;
(b) Nurse practitioner;
(c) Physician assistant;
(d) Mental/behavioral health providers.
(3) Payor of Last Resort.
(a) As required by 42 CFR 136.61, Samish PRC, acting on behalf of the Indian Health Service, is the payor of last resort under these regulations, notwithstanding any state or local law or regulation to the contrary.
(b) Accordingly, Samish PRC will not be responsible for or authorize payment for PRC to the extent that:
(i) The PRC enrollee is eligible for alternate resources; or
(ii) The PRC enrollee would be eligible for alternate resources if he or she were to apply for them.
(c) Samish PRC must first determine whether the patient applying for PRC funds is eligible. In addition, Samish PRC must determine that the medical services requested for payment from PRC funds are within medical priorities in STC 10.20.140.
(4) Alternate Resources.
(a) It is the policy of Samish Indian Nation to ensure maximum enrollment in all alternate resources (insurance), including Medicaid, Medicare, and private insurance. The Samish Tribal Council has approved the policy and procedure to facilitate alternate resource compliance.
(b) The use of alternate resources is mandated in 42 CFR 136.61. Indian Health Service regulations require an individual to apply for an alternate resource if there is a reasonable indication that the individual may be eligible and there is no cost to the individual.
(c) Samish PRC will make several attempts to notify a PRC enrollee of the need to apply for alternate resources and the failure to apply within 30 days will cause denial of payment by PRC for medical, dental and vision services/charges. These charges will then be the personal responsibility of the PRC enrollee.
(d) A PRC enrollee will be required to provide Samish PRC with income information when requested to determine alternate resource eligibility.
(e) If it is determined that the PRC enrollee or family may be eligible for an alternate resource, they must apply for that alternate resource in order to continue to be eligible for PRC benefits. Samish PRC will assist with any alternate resource application. Samish PRC will notify the PRC enrollee of the need to apply for an alternate resource.
(f) A PRC enrollee that fails to follow through with an application for an alternate resource will lose their PRC eligibility at the end of the 30-day period until proof of submitted application. [Res. 2020-10-013 § 2, 2020.]