Community , Health

ON Purchased Referred Care takes place of Pawnee Health Benefit package

The Wah-Zha-Zhi Health Center now provides medical referrals for diagnosis and treatment beyond provided clinic services. This service is called Purchase Referred Care and it takes the place of the Pawnee Health Benefit package.

The Purchase Referred Care (PRC) program serves those Osages and Native American patients residing within Osage County. Osages living within the boundaries of the Contract Health Service Delivery Area are also eligible. Those counties include Garfield, Grant, Kay, Noble, Osage, Pawnee and Payne counties only. 

According to the WHC, “This service includes out-patient specialty, emergency room, treatment for chronic illnesses and in-patient care.” According to WHC information about Purchase Referred Care: 

Eligibility

-       Must have active WHC chart or provide information to create a chart

-       Patient must be a member of a federally recognized tribe and reside in the Contract Health Service Delivery Area (CHSDA)

-       Patient must apply for any alternate resources available to them (a Patient Benefits Coordinator will assist with this). If you are eligible for SoonerCare (Title 19) you must accept it or not be eligible for a referral 

What needs to be done to enroll?

-       Make sure you have an up to date chart

-       Make sure all phone numbers are current

-       When seen at the Emergency Room or in-Patient Stay at a hospital, be sure to notify the WHC immediately by calling (918) 287-9388 

Documentation needed by WHC

-       CDIB or tribal membership card

-       Copy of current insurance coverage

-       Proof of residency 

Non-eligible Tribes

The following tribal members living within Osage County will continue to receive referrals from the Pawnee Service Unit:

-       Iowa Tribe of Oklahoma

-       Kaw Nation

-       Otoe-Missouria Tribe of Indians

-       Pawnee Nation of Oklahoma

-       Tonkawa Tribe of Indians of Oklahoma

-       Sac and Fox Nation

-       Ponca Tribe of Oklahoma 

Emergency Room

An emergency room visit can happen at any time, anywhere. The WHC services will cover any life or limb emergency at any hospital within the United States, so long as the patient has a current chart at the WHC. Opportunity will be provided for patients without a chart to create one following an ER visit, within three days of the visit. An emergency room visit determined to be a non-emergency will not be paid. 

Requirements for Emergency and In-Patient Services

-       Patients must live within the service area

-       Patients must notify the Medical Referral Program within three days of receiving either emergency room or in-patient services. Call in must be done by the patient or a family member

-       If not currently a patient with the WHC, it will be up to the patient or a close family member to meet with a Benefits Coordinator within the five-day period and provide all necessary information for services to be approved 

Out-Patient Specialty

Patients needing a specialist will be referred to a Contracted Provider of the WHC. A patient’s communication with the WHC Medical Referral Specialists plays a key role in the efficient processing of the patient’s referral. All referrals will be reviewed and approved, deferred or denied on a weekly basis. 

In-Patient Stays

An inpatient stay can happen at any time, anywhere. The WHC services will cover any in-patient stay at any hospital within the United States, so long as patients have a chart at the WHC. Opportunity will be provided for patients without a chart to create one within five days after entering the hospital. 

Therapies and Prolonged

Therapies and treatments such as cardio rehab, dialysis, post-op physical therapy, and chemotherapy are covered treatments. However, patients must use a contracted provider for these services. Please work with the Medical Referral Specialists prior to beginning treatment. 

To access this service

One of our providers evaluates your need and in their plan of care concludes you require services not provided in the WHC facility. A referral for this service is submitted to the committee for approval. With minor exception, all medical, dental, pharmacy, optometry, lab, and x-ray direct service are provided at “no charge” to the patient. All third-party insurance contributed to your care is a resource we receive to provide additional services and add to the quality of care of our patients. 

What is an Approved referral?

Medical Necessity or Priority

What can cause a denial?

-       Does not meet medical priority

-       Insufficient medical information

-       Incomplete Chart

-       Patient does not live in the service area

-       Did not notify ONPRC within the required 3-day period 

What can cause a deferment?

It is possible your referral can be deferred. Meaning the referral is postponed. This can be caused by funding, medical necessity or by an incomplete chart.

ASAP Referrals (automatically approved)

-       Asap referrals are medical emergencies that require timely lifesaving action for the patient

-       Referrals of this nature will be reviewed and if so approved moved to the highest priority for scheduling

Notify the WHC when you visit the Hospital or Emergency room within three days. Call the PRC Hotline at (918) 287-9388 and leave your name, your ONPRC Program number from your card, a good contact phone number, and the circumstances of your emergency.

It is important to make sure your chart is complete and up to date when you begin a referral. Medical Records should be faxed to (918) 287-6138.

Wah-Zha-Zhi Health Center

715 Grandview Ave.

Pawhuska, OK 74056

(918) 287-9300