ASK KANA: Purchased and Referred Care

“My provider suggested a service that is not available at KANA. Can I make an appointment with any local provider?”
“I went to see a chiropractor in town, but wasn’t referred. Is KANA going to pay?”
“My child broke their arm. Am I financially responsible for the emergency room services?”

Life is unpredictable. Circumstances may arise where Beneficiaries find themselves needing services not offered by KANA. It is your responsibility to understand your financial obligations for health services. Here’s what you need to know to ensure your costs are covered.

KANA Purchased and Referred Care (PRC) is NOT insurance, but rather a service that is federally funded by Indian Health Services (IHS), considered the payor of last resort.

Most preventative health care services are available at KANA or other tribal facilities, such as ANMC. “Excluded services,” or, services not otherwise medically necessary, are not covered by PRC, yet may be offered at KANA or ANMC. PRC funding is used only when KANA has no direct care capabilities and patients are seeking “approved services”—those considered medically necessary, or the condition of a patient is considered emergent. Beneficiaries receiving unauthorized care without a referral and are otherwise eligible for contract health care services will be financially obligated.

Staff will use fair and equal judgment when authorizing services, and will utilize medical priority guidelines to ensure funds remain available for all eligible KANA Beneficiaries. Ineligible Beneficiaries will be referred to ANMC or will be financially obligated to pay for services received outside of KANA. Medical priority guidelines define care as emergent, acutely urgent, urgent and non-urgent.

The IHS requires all eligible Beneficiaries to be screened for alternate resources. Alternate resources include: Medicaid, Medicare, Tribal Sponsored Health Insurance Program (TSHIP), DenaliKid Care, and insurance you may have through your employer or have purchased privately.

Once screened, you will be required to make a “good faith” effort to apply for resources available to you; failure to do so will leave you financially obligated to pay for services received outside of KANA. Beneficiaries with alternate resources that have received authorized care qualify for PRC to pay the remaining balances for services received.

All emergency care received at a non-tribal facility must be reported to the Purchased and Referred Care office within 72 hours. Before PRC will authorize payment, emergent care will be reviewed based on: a Beneficiary’s eligibility, compliance with the notification policy, a patient’s clinical information, and whether the visit was considered medically necessary. KANA PRC will not authorize payment in cases where a Beneficiary failed to follow KANA’s emergency care policy.

Beneficiaries wishing to remain in Kodiak for their health care needs will be considered self-referred. Self-referred patients with alternate resources receiving approved services under PRC guidelines qualify for KANA PRC to pay the remaining balance after insurance claims. Excluded services will not be covered. Patients who do not qualify for alternate resources and do not have private insurance will be financially obligated should they choose to receive services locally.

As a member of your own care team, it is your responsibility to ask questions about KANA’s healthcare policy and to follow up with PRC when seeking referred and non-referred care.

If you would like more information on KANA’s PRC policy, approved/excluded services, or about applying for alternate resources, contact KANA’s Purchased and Referred Care Specialist at 907.486.9828.

What is the criteria for an “Eligible Beneficiary”?

An Eligible Beneficiary:

  • has been a resident of Kodiak for 90 days or more
  • has provided a Certificate of Indian Blood (CIB)
  • is enrolled in a federally recognized tribe
  • is a Pregnant mother of a child that is eligible for PRC
  • is a child of an eligible IHS Beneficiary, including adopted, step-child, foster child, orphan, or legal ward, until age 19.

To find out if you meet KANA’s eligibility requirements, contact Stacey Wolkoff or Rosa Cruz at 907.486.9828