All non-IHS primary care services must be prior-authorized before obtaining services. If you live within 25 miles of an IHS (Indian Health Service/Tribal/Urban-ITU) facility, you must first use this resource for your primary care services.
Patient must be referred to a specialist from an IHS provider due to medial necessity. The patient may not self-refer to a specialist.
A written referral or any other pertinent information is required and must be submitted to PRC prior to scheduling an appointment. The information will be reviewed and a decision made as to acceptance or denial of specialty services.
- 0-18 years – Annual Exam, Frame and Lenses every year
- 19-64 years – Annual Exam, Frame and Lenses every two years
- 65+ years – Annual Exam, Frame and Lenses every year
If you are diabetic, the diabetes program may pay for your eye exam.
- One initial or periodic oral exam 2 times per year (once every 6 months)
- Dental cleaning 2 times per year (once every 6 months)
- X-rays, fluoride/sealants
All other dental services, including specialised services, provider will need to submit treatment plan.
- Amalgam Restorations/Composite Restorations (fillings)
- Children’s prefabricated crowns for primary (baby) teeth
- Endodontics (root canals)
- Oral Surgery
- Periodontal care
- Orthodontic Services (braces) for members 19 years and younger
Dental services will need pre-authorization from Purchased/Referred Care. Please submit a pre-determination estimate on an ADA claim form. Your dental office should be able to provide this to you or they may submit directly to PRC. Also, have your dentist include any supporting documents, i.e. radiographs, chart notes and/or a narrative to support their recommendations. Cosmetic procedures will not be approved
The below dental procedures are of a lower priority. 20% of the PRC dental budget will be reserved for dental services including, but not limited to:
- Crown and bridge procedures. (Ceramic and porcelain fused to noble metal allowed. No gold crowns or bridges.
- Dentures or partials fabricated by Affordable Dentures located at Lincoln/Bellevue, NE and Sioux City, IA.
- Dentures/partials may be fabricated at Creighton University School of Dentistry when required and appropriate approval is obtained.
- Mini implants/Implants if placed by Affordable Dentures or Creighton University School of Dentistry.
Emergency office visit/exam and necessary treatment to alleviate the emergent condition.
Dental Service Plan
Emergent care services are diagnostic or therapeutic services that are necessary to prevent the immediate death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitates the use of the most accessible health care available and capable of furnishing such services. Diagnosis and treatment of injuries or medical conditions that, if left untreated, would result in uncertain but potentially grave outcomes. All emergency services will be reviewed by PRC Committee to determine of the service meets Medical Priority One approval.
All prescriptions obtained by a non-IHS provider whose referral was initiated from an IHS primary care provider, must exhaust all means of assistance through the I/T/U pharmacy. If unavailable, PRC will consider authorization to a non-IHS pharmacy.
Prescriptions obtained by a non-IHS provider may be authorized at a non-IHS pharmacy of the member resides 25 miles or greater from the nearest IHS facility.
Other Funding Sources
All alternate resources must be exhausted. Please contact the following State programs for potential coverage.
Iowa Health and Human Services
Breast and Cervical Cancer Early Detection/WISEWOMAN
Iowa Department of Public Health
PRC is a payer of last resort. When a patient has Medicare, Medicaid, Veteran’s benefits, private insurance, worker’s compensation, or is covered by any other resource, that resource is the primary carrier. Patients must immediately provide all explanations of benefits from the primary carrier(s) to the PRC office when received by the patient. If the patient has Medicaid, PRC does not pick up any remaining balances because the provider must accept Medicaid’s payment as full payment.