AZ
"SECTION D:
PROGRAM REQUIRMENTS
1. SCOPE
OF SERVICES...
Covered services
must be medically necessary and provided by, or coordinated with, a primary
care provider, except for behavioral health and children's preventive dental
services…" Arizona Contract, page 10.
"2. BEHAVIORAL
HEALTH SERVICES...
Coordination
of Care: The Contractor is responsible for ensuring that a medical record
is established by the PCP when behavioral health information is received
from the RBHA or provider about an assigned member even if the PCP has
not yet seen the assigned member...
Medication
Management Services: ...
The Contractor shall ensure that training and education is available to PCPs regarding behavioral health referral and consultation procedures...Also, Contractors shall inform PCPs about the availability of training and education through the Regional Behavioral Health Authorities regarding the diagnosis and treatment of behavioral health disorders." Arizona Contract, pages 16-17.
"22. PRIMARY
CARE PROVIDER STANDARDS...
At a minimum,
the Contractor shall hold the PCP responsible for the following gatekeeping
activities:
a. Supervision,
coordination and provision of care to each assigned member
b. Initiation
of referrals for medically necessary specialty care
c. Maintaining
continuity of care for each assigned member
d. Maintaining
the member’s medical record, including documentation of all services provided
to the member by the PCP, as well as any specialty or referral services.
The Contractor shall establish and implement policies and procedures to monitor PCP gatekeeping activities and to ensure that PCPs are adequately notified of, and receive documentation regarding, specialty and referral services provided to assigned members by specialty physicians, dentists and other health care professionals...PCPs and specialists who provide inpatient services to the Contractor’s members shall have admitting and treatment privileges in a minimum of one general acute care hospital that is located within the Contractor’s service area." Arizona Contract, page 32.
"44. MEDICAL
RECORDS...
When a member
changes PCPs, his or her medical records or copies of medical records must
be forwarded to the new PCP within 10 working days from receipt of the
request for transfer of the medical records." Arizona Contract, page
45.
AZBH
"ADHS shall ensure that the subcontracted RBHAs/providers send written notification, and the results of the evaluation and information regarding the planned course of treatment to the member's PCP, whether or not the PCP was the referral source." Arizona Behavioral Health Contract, page 15.
"8. ASSIGNED
CLINICIAN
Maricopa County
GSA: ADHS shall ensure that each Title XIX or Title XXI member in
the Maricopa County GSA identified by evaluation as needing covered behavioral
health services is assigned to a clinician who is either a psychiatrist,
certified psychiatric nurse practitioner, registered nurse, psychologist,
physician assistant as defined in this contract, certified social worker,
certified professional counselor, certified marriage and family therapist
or certified substance abuse counselor...
The Title XIX and Title XXI member is assigned to an assigned clinician who directly performs or is responsible for clinical supervision of the following activities:
a. Ongoing
assessment of existing and emerging behavioral health needs.
b. Development,
implementation and revision, as needed, of a service plan for active treatment
and/or rehabilitation with revision of service delivery based on progress
towards behavioral health goals.
c. Maintenance
of a complete and comprehensive behavioral health record of all covered
services provided to the member, in accordance with AHCCCS and ADHS/DBHS
policy.
d. Provision
of, or referral to, needed treatment, rehabilitative, supportive and ancillary
covered services, including case management and referral to community resources.
e. Monitoring
of behavioral health condition, and provision of intervention as needed.
f. Ongoing
collaboration with parents, guardians, family members, primary care physicians,
school, child welfare, juvenile or adult probation and/or parole, Developmental
Disability provider, community and state agencies and other involved service
providers.
g. Maintenance
of continuity of care between inpatient and outpatient settings.
h. Facilitation
and coordination of transfers out of area, out of state, or to an AHCCCS
long term care contractor, as applicable.
i. Development
and implementation of transition, discharge, and aftercare plans prior
to discontinuation of behavioral health services.
j. By
January 1, 2000, ADHS shall develop and submit a plan for implementation
of the assigned clinician model for all other GSAs." Arizona Behavioral
Health Contract, pages 15-16.
"9. CASE
MANAGEMENT SERVICES...
In Maricopa
county, case management services shall be provided by, or under the clinical
supervision of, the primary behavioral health professional to whom the
member is assigned as described in Paragraph 8 of this contract."
Arizona Behavioral Health Contract, page 16.
"14. COORDINATION
WITH AHCCCS ACUTE CARE CONTRACTORS...
ADHS shall
ensure that the behavioral health records, copies, or summaries of relevant
information of each Title XIX and Title XXI member are forwarded to the
member's PCP at initiation of treatment, periodically during on-going treatment,
regarding sentinel events and at discharge from services to provide information
needed to accomplish medical management… At a minimum, the PCP should be
notified in the following circumstances:
a. Initiation
and significant changes in psychotropic medications and significant adverse
reactions
b. Results
of laboratory, radiology and other tests
c. Emergency
crisis admissions or events
d. Events
requiring medical consultation with PCP
e. Discharge
from an inpatient setting
f. Disenrollment
from ADHS/RBHA
g. Initial
Behavioral health evaluations, including outcome of screening
ADHS and its subcontracted RBHAs must adhere to confidentiality guidelines pursuant to 42 CFR 431. Unless prescribed otherwise in statute, it is not necessary for ADHS subcontracted RBHAs to obtain a signed release form in order to share information with the PCP...
ADHS will ensure that information is available to health plan PCPs regarding subcontracted RBHA referral and consultation procedures. Upon request, ADHS will provide education and training to health plan PCPs regarding diagnosis and treatment of behavioral health disorders." Arizona Behavioral Health Contract, pages 18-19.
CA
"ARTICLE II
- DEFINITIONS...
V1. Primary
Care Physician means a Physician responsible for supervising, coordinating,
and providing initial and Primary Care to patients; for initiating referrals
for specialist care; and for maintaining the continuity of patient care...
W1. Primary Care Provider means a person responsible for supervising, coordinating, and providing initial and Primary Care to Members; for initiating referrals and for maintaining the continuity of Member care." California Contract, pages 2, 11-12.
"6.9.10 Primary
Care Physician Assignment...
In all cases
where a nurse practitioner or certified nurse midwife is a Member's Primary
Care Provider, Contractor shall assure that an individual Primary Care
Physician is responsible for the overall coordination of the Member's health
care, consistent with applicable State and federal laws and regulations…"
California Contract, pages 138-139.
CO
"I. DEFINITIONS
The following
terms as used in this Contract shall be construed and interpreted as follows
unless the context otherwise expressly requires a different construction
and interpretation: ...
BG. 'Primary Care Physician' or 'Participating Primary Care Physician' shall mean the Physician who has entered into a professional service agreement to serve the Contractor's Members and has been designated by the Member, or the Member’s legal guardian as the Physician who will attend to the Member's routine medical care, supervise and/or coordinate all of the Member's health care, to and initiate all referrals." Colorado Contract, page 10.
"XIV.
SERVICE DELIVERY…
D. Preventive
Health Services
1. The Contractor
shall establish and maintain a comprehensive program of preventive health
services for Members that is used to minimize the risk of preventable illness
and Secondary Disability and promote the highest level of wellness and
appropriate self-care among Members.
2. The program
of preventive health services shall include, but is not limited to:
a.
risk assessment by a Member’s Primary Care Provider or other qualified
professionals specializing in risk prevention who are part of the Contractor’s
provider network or under contract to provide such services, to identify
Members with chronic/high risk illnesses, Disabilities, or the potential
for such conditions…" Colorado Contract, pages 46, 51.
"XVIII. MEMBER
RIGHTS AND RESPONSIBILITIES
A. Member Rights
The Contractor
shall establish and maintain written policies and procedures for
treating all Members in a manner that is consistent with all rights
enumerated in 10 CCR 2050-10, § 8.207.5, as well as the following:
7. to
receive from the Member's Primary Care Physician, in terms that the Member
understands, an explanation of his or her complete medical condition, recommended
treatment, risk(s) of the treatment, expected results and reasonable medical
alternatives…" Colorado Contract, page 58.
"EXHIBIT A
COVERED SERVICES...
DEFINITION:
A covered services shall be deemed medically necessary if, in a manner
consistent with accepted standards of medical practice ...
The medical necessity of a covered service shall be determined by the Contractor and the Member's PCP, in consultation with the Member or Member's guardian..." Colorado Contract, Exhibit A, page 1.
CT
"Part II:
General Contract Terms for MCOs
1. Definitions...
JJ. Primary
Care Provider (PCP): A specific clinician responsible for coordinating
the health care needs of certain Members…" Connecticut Contract,
pages 11-14.
DE
"8.1 PCP
Responsibilities
The primary
care provider serves as the member's initial and most important contact.
As such, primary care provider responsibility must at a minimum include:
(a) Maintaining continuity of each member's health care by serving as the member's primary care provider
(b) Providing twenty-four (24) hour, seven (7) day a week access
(c) Making referrals for specialty care and other medically necessary services, both in-plan and out-of-plan
(d) Maintaining a current medical record for the member, including documentation of all services provided to the member by the PCP, as well as any specialty or referral services. Ensure that reports from all referral services are included in the PCP medical record.
(e) Adhering to the EPSDT periodicity schedule for members under age twenty-one (21)
(f) Following MCO established procedures for coordination of in-network and out-of-network services for members
Although PCPs must be given responsibility for the above activities, the MCO also must agree to retain responsibility for monitoring PCP actions to ensure they comply with MCO and Delaware Medicaid managed care program policies." Delaware RFP, page II.53.
HI
"30.100
Offerors' Role in Managed Care...
The plan shall
also provide each recipient with a primary care provider who assesses the
recipient's health care needs and provides/directs the services to meet
these needs." Hawaii RFP, page 8.
"30.420
Primary Care Provider (PCP)...
The function
of the PCP shall be to assess a recipient's health care needs and to provide
services to meet these needs either directly or through the plan's provider
network... A health plan which intends to utilize specialists and/or nurses
as PCP's shall submit a plan for monitoring their performance as a PCP
to DHS for approval prior to implementation..." Hawaii RFP, pages
9-10.
"Primary care provider or PCP - is licensed in Hawaii and is 1) a physician, either an M.D. (Doctor of Medicine) or a D.O. (Doctor of Osteopathy), and must generally be a family practitioner, general practitioner, general internist, pediatrician or obstetrician/gynecologist (for women, especially pregnant women); or 2) a nurse practitioner, and must generally be a family nurse practitioner, pediatric nurse practitioner or nurse midwife. Has the responsibility for supervising, coordinating and providing initial and primary care to the enrollee and for initiating referrals and maintaining the continuity of enrollee care." Hawaii RFP, Appendix A, page 5.
HIBH
"30.100 Offerors
Role in Managed Care...
Since BHMC
plan members will retain their primary care provider (PCP) (through the
QUEST health plan) for coordination of QUEST medical services, the BHMC
plan shall ensure the PCP is regularly updated on the member's diagnosis,
treatment plans and ongoing care and that close coordination with the member's
medical care is maintained." Hawaii Behavioral Health RFP, page 14.
IL
"(o) Choice
of Physicians
The Contractor
shall afford to each Beneficiary a physician who will supervise and coordinate
his/her care, and to the extent feasible, within appropriate limits established
by the Contractor and approved by the Department, shall afford the Beneficiary
a choice of a physician..." Illinois HMO Contract, page 45.
IN
"3.2.2
Primary Medical Providers
Hoosier Healthwise
allows eligible Medicaid recipients to select a PMP who provides, through
an ongoing recipient/PMP relationship, preventive and primary medical care,
as well as authorization and referral for all medically necessary specialty
services. The PMP is available 24-hours a day, seven days a week,
and assumes total management of the Medicaid recipient's non-emergency
medical needs." Indiana RFP, page 3-7.
"3.2 Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children: (Section 2102)(a)(4)
Hoosier HealthWise has a number of utilization control mechanisms in place that are designed to ensure that health care use is appropriate and medically necessary. These mechanisms will be utilized under Phase II of the CHIP Program...
The managed care system established under Hoosier HealthWise also has some built in utilization controls. The PMP serves as a gatekeeper who provides or authorizes primary care services and makes referrals for specialty care (except those which may be self-referred) when appropriate. Referrals must be documented in the patient's medical record." Indiana SCHIP Amendment, Attachment C-3, page 14.
IA
"1.3 Definitions...
- Primary Care
Physician (PCP) - a physician under contract with the HMO who is duly licensed
and certified under the laws of the state of Iowa. A Primary Care
Physician shall be responsible for the initial and primary care given to
an Enrollee and shall be a general practitioner, internist, family practitioner,
pediatrician or any other physician approved by the HMO. If an Enrollee
suffers from a chronic condition lasting, or anticipated to last, more
than 12 months, and both the Provider and the Enrollee agree to provide
and receive, respectively, a full spectrum of primary care services, other
specialty Providers may be enrolled/assigned as a PCP." Iowa Contract,
pages 6, 9.
IABH
"E. Oversight
of the Utilization of Psychotropic Medications (proposal Section 7A.2.14)...
MBC of Iowa,
with input from the Iowa Drug Utilization Review Commission, providers
and PCPs, will include in the provider manual requirements to screen for
any known drug allergies, other medications they are currently taking,
changes in medications, adverse reactions to medications, changes to medical
status and whether the client is pregnant. This screening will be
required at the onset of treatment and regularly throughout treatment...
MBC of Iowa will distribute an Iowa Plan manual, provider releases and educational materials to MBC of Iowa network providers as well as PCPs regarding coordination and communication of medication management, standards for preventing drug interactions and screening for drug allergies and pregnancy." Iowa Behavioral Health Contract, pages 59-60.
KY
"7.6.3
Primary Care Provider Responsibilities
The
definition of a primary care provider (PCP) is a licensed or certified
health care practitioner, including a …that functions within the scope
of licensure or certification, has admitting privileges at a hospital or
a formal referral agreement with a provider processing admitting privileges,
and agrees to provide 24 hours per day, seven days a week primary health
care services to individuals. Primary care physician residents may
function as PCPs. The PCP shall serve as the member's initial and
most important point of contact with The Partnership. This role requires
a responsibility to both The Partnership and the Member...
Specialty providers may serve as PCPs under certain circumstances, depending on the member's needs...
PCP responsibilities
shall include at a minimum:
(a)
Maintaining continuity of each member's health care;
(b)
Making referrals for specialty care and other medically-necessary services,
both in and out of plan;
(c)
Maintaining a current medical record for the Member, including documentation
of all PCP and specialty care services;
(d)
Discussing advance medical directives with all Members as appropriate;
(e)
Providing 24-hour-per-day, seven-days-a week access to services and access
to medically-necessary emergency services;
(f)
Providing or arranging for all necessary preventive health care, including
EPSDT for persons under the age of 21 years; and
(g)
Maintaining formalized relationships with other PCPs to see their members
for after hours care, during certain days, for certain services, or other
reasons to extend their practice. The PCP remains solely responsible
for the PCP functions (a) through (f) above." Kentucky RFA, pages
43-44.
ME
"II. DEFINITIONS.
A. The
following terms used in this Contract shall be interpreted as defined herein,
except to the extent that the context may clearly require otherwise: ...
45. Primary
Care Provider (‘PCP’) is the individual practitioner or team selected to
provide and coordinate all of the Enrollee's health care needs and to initiate
and monitor referrals for specialized services when required." Maine
Contract, pages 2, 7.
"3.4 SERVICE
DELIVERY...
B. PRIMARY
CARE PROVIDERS...
1. PCP
Teams. The Contractor is encouraged to establish primary care provider
teams that include certified nurse midwives, certified nurse practitioners,
or physician assistants who, at the Enrollee's discretion, may serve as
the point of first contact for the Enrollee. If the Contractor's primary
care network includes institutions with teaching programs, primary care
provider teams, comprised of residents and a supervising faculty physician,
may serve as a PCP. The Contractor shall organize its PCP teams so as to
ensure continuity of care to members, and shall identify a lead physician
within the team for each member. The lead physician must be an attending
physician and not a resident." Maine Contract, pages 25-26.
MD
"10.09.64.10...
.10 Special
Needs Populations.
An MCO applicant
shall include in its application the following information and descriptions:
...
D. Referral
protocols that demonstrate the conditions under which PCPs will make the
arrangements for children with special health care needs to be referred
to specialty care networks." Maryland COMAR 10.09.64.10.
MA
"SECTION 1.
DEFINITION OF TERMS...
Primary Care
Practitioner (PCP) - the individual Primary Care Practitioner or team selected
by the Enrollee, or as assigned to the Enrollee by the Contractor, to provide
and coordinate all of the Enrollee's health care needs and to initiate
and monitor referrals for specialty services when required…" Massachusetts
Contract, pages 6-14.
MI
"DEFINITIONS/EXPLANATION
OF TERMS...
PCP
Primary Care
Provider. Those providers within the Health Plans who are designated
as responsible for providing or arranging health care for specified Enrollees
of the Contractor…" Michigan Contract, pages vi, viii.
"II-M CONTRACTOR
ORGANIZATIONAL STRUCTURE, ADMINISTRATIVE SERVICES, FINANCIAL REQUIREMENTS
AND PROVIDER NETWORKS...
6. Provider
Network in the CHCP...
(i) PCP Standards...
The PCP is
responsible for supervising, coordinating and providing all primary care
to each assigned Enrollee. In addition, the PCP is responsible for
initiating referrals for specialty care, maintaining continuity of each
Enrollee's health care, and maintaining the Enrollee's medical record which
includes documentation of all services provided by the PCP as well as any
specialty or referral services…" Michigan Contract, pages 32, 35,
39.
MO
"a. Primary Care Provider Responsibilities: The health plan must have written policies and procedures for limiting every member to a primary care provider. The primary care provider must serve as the member's initial and most important contact. As such, primary care provider responsibilities must include at a minimum:
1) Maintaining
continuity of each member's health care.
2) Making
referrals for specialty care and other medically necessary services, both
in plan and out of plan.
3) Maintaining
a comprehensive current medical record for the member, including documentation
of all services provided to the member by the primary care provider, as
well as any specialty or referral services, diagnostic reports, physical
and behavioral health screens, etc.
4) Although
primary care providers must be given responsibility for the above activities,
the health plan also must agree to retain responsibility for monitoring
primary care provider actions to ensure they comply with health plan and
MC+ program policies.
5) Primary
care providers may have formalized relationships with other primary care
providers to see their patients for after hours care, during certain days,
for certain services, or other reasons to extend their practice.
However, the primary care provider retains sole responsibility for those
functions in Performance Requirements segment, Item 2.2, paragraphs 2.2.2
a 1 through 2.2.2 a 4…" Missouri RFP, page 24.
MT
"PRIMARY CARE PROVIDER (PCP)…The duties of the PRIMARY CARE PROVIDER shall be attending to the ENROLLEE's routine medical care, to supervise and coordinate all of the ENROLLEE's health care, to determine the need for and initiate all referrals, and to determine who shall perform medical services and whether the medical service is to be performed." Montana Contract, page 29.
NE
"11.6 Public
Health Nursing (PHN): A major component of the NHC is Public Health Nursing
(PHN)...
11.6.1 Referrals
to the PHN: Referrals to the PHN may be initiated by the PCP/plan, Department,
or other appropriate individuals.
11.6.2 PHN
as a Resource to the PCP/Plan: The EBS is a resource to the PCP/plan and
the client...
11.6.3 PHN
Coordination with PCP: The PHN component works as an extension of the PCP
to improve the health and wellness of the client, but only after the PCP/plan
has exercised his/her responsibilities.
11.7 Reasons
for Referral: The EBS shall be responsible for promoting effective utilization
of health resources to enable clients to better manage their own health
care... Intervention by the EBS may occur in, but is not limited to, the
following situations:...
(b) Serving
as a resource to the PCP/plan in identifying other state and community-based
agencies that provide vital health and social supports for clients;
(c) Assisting
the PCP/plan in complying with federal requirements for HEALTH CHECK (EPSDT)
services; and
(d) Assisting
the PCP/plan in providing services to high-risk pregnant women and their
infants, taking into account age, education, alcohol or drug use/abuse,
weight, medical and psychosocial conditions and the need to ensure access
to needed medical, social, educational and other services...
11.10 Documentation
of Requests for PHN Services: The EBS shall document each request for PHN...
11.10.1 PCP
Follow-up: The EBS shall contact the PCP within five working days of the
request.
11.10.2 Development
of a Care Plan: The PHN, in partnership with the client, PCP/plan, or other
pertinent entities, shall develop a plan to address the needs identified
in the assessment process to promote optimum levels of health and ensure
the client is able to receive maximum benefits from medical intervention.
11.11 Coordination
with the PCP/Plan and Healthcare Delivery Team: The PHN shall, in partnership
with the client, coordinate with the PCP/plan information obtained regarding
health status, lifestyle, and other information relevant to case management
of the individual client.
11.11.1 PCP/Plan
Consultation: The PHN shall present written reports and documentation to
the PCP/plan, as appropriate, and consult in person or by telephone with
the PCP/plan regarding the client according to established EBS protocols.
11.12 HEALTH
CHECK (EPSDT) Outreach:...The EBS shall work cooperatively with the PCP/plan
to:
(a) Promote
preventive health care and encourage eligible children to receive HEALTH
CHECK (EPSDT) screening examinations according to the American Academy
of Pediatrics periodicity schedule.
(b) Receive
referrals from the PCP/plan regarding children who missed screening appointments
without cancellation based on guidelines established by the Department;
contact with families to determine barriers to care, to assist in rescheduling
appointments, and to counsel families about keeping appointments;
(c) Receive
referrals from the PCP/plan regarding children who are screened, referred
for further diagnosis and/or treatment and who did not follow-up with treatment
services per guidelines set forth by the Department; contact families to
determine barriers to care and to assist the families in initiating care
in a manner that is supportive to the family…" Nebraska Contract,
pages 64-66.
"13.3.1 Functionality of the PCP: The client chooses or is assigned to a Primary Care Physician (PCP). The PCP is the physician who provides a "medical home” for the client and is responsible for referrals for all medically necessary services. PCPs may participate in one or all of the HMOs, and/or in the Primary Care Case Management (PCCM) Network, which is addressed under a separate contract..." Nebraska Contract, page 78.
"13.7 PCP Qualifications
and Responsibilities: Under the contractual responsibilities of the plan,
the plan shall ensure that the PCP: ...
(2) Provide
the Basic Benefits Package per 471 NAC to all clients who choose or are
assigned to the PCP’s practice...
(3) Coordinate
appropriate referrals when medically necessary to services that typically
extend beyond those services provided directly by the PCP...
(4) As appropriate,
work cooperatively with specialists, consultative services and other facilitated
care situations for special needs clients...
(5) Provide
continuous access to PCP services and necessary referrals of urgent or
emergent nature available 24-hour, 7 days per week...
(6) Not refuse
an assignment or disenroll a client or otherwise discriminate against a
client...
(7) Ensure
that ADA requirements and other appropriate technologies are utilized in
the daily operations of the physician’s office...
(10) Maintain
a medical record for each client and comply with the requirement to coordinate
the transfer of medical record information if the client changes to another
PCP;
(11) Utilize
the Enrollment Broker Services and Public Health Nursing components of
the NHC pursuant to this contract, as appropriate;
(12) Maintain
a communication network that provides necessary information to any MH/SA
services provider as frequently as necessary based on the client’s needs...
The PCP shall
coordinate the provision, authorization, payment and the continuity of
care, and the plan shall monitor overall coordination between these two
service areas, i.e., medical/surgical and MH/SA….
(13) Communicate
with agencies such as, but not limited to, local public health agencies
for the purpose of participating in immunization registries and programs...
(14) Comply
with all disease notification laws in the State;
(15) Provide
information to the Department as required…" Nebraska Contract, pages
80-81.
NEBH
"4.1 Applicable
Definitions: The following definitions apply under this contract: ...
4.1.35
The term ‘Primary Care Physician (PCP)’, for purposes of the Basic Benefits
Package, means a medical/surgical plan-credentialled physician chosen by
the client or assigned by the Department who provides a ‘medical home’
for the client and whose primary expertise is in family practice, pediatrics,
general practice, internal medicine, or obstetrics/gynecology…" Nebraska
Behavioral Health Contract, pages 6, 11.
NV
"K. Primary
Care Physician (PCPs) or Primary Care Sites (PCSs) Responsibilities.
The PCP or a physician in a PCS must serve as the participant's initial
point of contact with the Contractor. As such, the PCP's or the physician
at the PCS, responsibilities include the following:
1.
Delivery of medically necessary primary care services and preventive services,
including DPSDT screening services;
2.
Provision of 24 hour, 7 days a week coverage;
3.
Referrals for specialty care and other medically necessary services covered
in the Medicaid benefit package;
4.
Continuity and coordination of the participant's health care; and
5.
Maintenance of a current medical record for the participant, including
documentation of all services provided by the PCP and specialty or referral
services or out of plan services such as family planning and emergency
room services.
Although PCPs must be given responsibility for the above activities, the Contractor must agree to retain responsibility for monitoring PCP actions to ensure they comply with the Contractor's and the state's requirements.
The Contractor is prohibited from imposing restrictions for the above activities. The Contractor must agree to retain responsibility for monitoring PCP and PCS actions to ensure they comply with the Contractor's and the state's requirements." Nevada Contract, pages 35-36.
NJ
"ARTICLE 10
COVERED HEALTH
CARE SERVICES...
Subject to
any limitations in the benefits package, each primary care physician shall
provide health counseling and advice; conduct baseline and periodic health
examinations; diagnose and treat covered conditions not requiring the referral
to and services of a specialist; arrange for inpatient care, for consultation
with specialists, and for laboratory and radiological services when medically
necessary; coordinate referrals for dental care, especially in accordance
with EPSDT requirements; coordinate the findings of laboratories and consultants…The
primary care physician shall also be responsible, subject to any limitations
in the benefits package, for determining the urgency of a consultation
with a specialist and, if urgent, shall arrange for the consultations appointment…"
New Jersey Contract, pages 51-52.
"1.93 'Primary Care Physician' or 'PCP' means a licensed medical doctor (MD) or doctor of osteopathy (DO) who is responsible for providing all required primary care services to enrollees…coordination of overall medical care...and initiation of referrals to specialty providers described in this contract and the Benefits Package, and for maintaining continuity of patient care." New Jersey Contract, page 20.
"HealthStart
Maternity Care Services
OVERVIEW
The primary objective of HealthStart maternity care services is to provide
women in New Jersey with a comprehensive package of care which addresses
all areas of their lives likely to affect their pregnancy outcomes and
the health of their infants...
The services are a 'package' in the sense that ONE primary provider…is
responsible for coordinating all of the services and ensuring that they
are delivered in the appropriate fashion...
Certain principles have guided development of the program regulations and
guidelines. Stating these principles will assist the provider to
implement the spirit as well as the requirements of the maternity care
package.
1.
The primary provider carries the RESPONSIBILITY for insuring that services
are available, accessible, and that the client understands the need for
and is supported to receive early and continuous maternity care.
In keeping with the principle, the provider is responsible for minimizing
all potential barriers to services such as waiting time, language barriers,
and physical distance and/or fragmentation…" New Jersey Contract,
Attachment 3, page 3.
NM
"2.C.2
The Primary Care Provider (‘PCP'):
The PCP must
be a medical provider participating with the MCO who has the responsibility
for supervising, coordinating, and providing primary health care to members,
initiating referrals for specialist care, and maintaining the continuity
of the member's care. The CONTRACTOR shall distribute information
to the network providers which explains the Medicaid-specific policies
and procedures that relate to PCP responsibilities. The CONTRACTOR
is prohibited from excluding providers as primary care providers based
on the proportion of high-risk patients in their caseloads...
2.C.3
Primary Care Responsibilities
The CONTRACTOR
shall ensure that the following primary care responsibilities are met by
the PCP, or in another manner:
2.C.3.a
Providing twenty-four (24) hour, seven (7) day a week access;
2.C.3.b
Ensuring coordination and continuity of care with providers who participate
with the MCO network and with providers outside the MCO network according
to MCO policy…
2.C.4
MCO Responsibility for PCP Services:
The CONTRACTOR
shall retain responsibility for monitoring PCP activities to ensure compliance
with MCO and HSD policies. The MCO shall educate PCPs about special
populations and their service needs. The CONTRACTOR shall ensure
that PCPs successfully identify and refer patients to specialty providers
as medically necessary." New Mexico Contract, pages 27-28.
NY
"21. PARTICIAPTINGG
PROVIDERS...
21.9
PCP Responsibilities
In conformance
with the Benefit Package, the PCP shall provide health counseling and advice;
conduct baseline and periodic health examinations; diagnose and treat conditions
not requiring the services of a specialist; arrange inpatient care, consultation
with specialists, and laboratory and radiological services when medically
necessary; coordinate the findings of consultants and laboratories; and
interpret such findings to the Enrollee and the Enrollee's family, subject
to the confidentiality provisions of Section 20 of this Agreement, and
maintain a current medical record for the Enrollee. The PCP shall
also be responsible for determining the urgency of a consultation with
a specialist and shall arrange for all consultation appointments within
appropriate time frames…" New York Contract, pages 21-1-21-6.
ND
"Primary Care
Provider (PCP)...
The duties
of the primary care provider shall be attending to the enrollee's routine
medical care, to supervise and coordinate all of the enrollee's health
care, to determine the need for and initiate all referrals, and to determine
who shall perform medical services and whether the medical service is to
be performed." North Dakota Contract, Attachment C, page 6.
OH
"E. Service
Delivery Specifications
1. Primary
Care Physician Responsibility...
Primary care
physicians are required to:
* Act
as the case manager for their designated enrollees' overall care and participate
in the development of a team approach to clinical care and case management.
* Act as the referring physician for enrollees requiring access to a specialty service.
* Coordinate emergency care, including care provided in hospital emergency departments, for enrollees.
* During
regular office hours, provide a telephone coverage system and on-site staffing
capacity to:
-
respond to enrollee's medical questions;
-
determine enrollee care needs;
-
respond to emergency inquiries; and
-
set appointments or make referrals in accordance with the requirements
specified in OAC rule 5101:3-26-031(D)..." Ohio RFP, pages 14-15.
OK
"1.4 Definitions
Each of the
following terms shall have the indicated meanings unless the context clearly
requires otherwise: ...
59. PRIMARY CARE PROVIDER (PCP) means the individual practitioner or team selected by, or assigned to a particular ENROLLEE to provide and coordinate all of the enrollee's primary care needs and to initiate and monitor referrals for specialized services when required…" Oklahoma RFP, pages 5, 11.
"2.7 Provider
Network...
2.7.2
Primary Care Providers
2.7.2.1
Responsibilities...
PCP responsibilities
must include at least the following:
• Delivering
medically necessary primary care services, including EPSDT screening services
for children and adolescents;
• Making referrals
for specialty care and other medically necessary services and coordinating
wraparound services and
• Maintaining
a current medical record for the member…" Oklahoma RFP, page 32.
"2.7.4
Behavioral Health Access & Utilization Management...
The Health
Plan agrees that PCP shall make appropriate referrals to behavioral health
providers…" Oklahoma RFP, page 36.
ORMH
"e. Physical
Health Care Providers
Contractor
shall coordinate with physical health care providers and Fully Capitated
Health Plans as follows:
(1) Consult
and communicate with OMAP Member's physical health provider as Medically
Appropriate and within laws governing confidentiality as specified in OAR
410-141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping.
(2) Consult
with, and provide technical assistance to, physical health care providers
in the Service Area to help assure that mental disorders are identified
early so that intervention and prevention strategies can begin as soon
as possible.
(3) Develop
and implement methods of coordinating with FCHPs in order to assure access
and appropriate coordination of services delivered to mutual OMAP Members,
particularly OMAP Members with exceptional service needs. Such coordination
shall be conducted within laws governing confidentiality." Oregon
Mental Health Contract, page 18.
PA
"Primary Care
Practitioner (PCP) — A specific physician, physician group, health center,
or a CRNP operating under the scope of their licensure who has received
an exception from the Department of Health, responsible for providing primary
care services and locating, coordinating,
and monitoring
other medical care and rehabilitative services on behalf of a recipient…"
Pennsylvania RFP, page xii.
"A. DESCRIPTION
OF THE HEALTHCHOICES PROGRAM...
2. Background
In contrast
to the FFS system, managed care is provided through a health care delivery
system in which a Primary Care Practitioner (PCP) or group of PCPs is responsible
for providing, coordinating, and managing the health care needs of the
individual patient. The PCP is responsible for facilitating access to specialty
services when medically necessary and ensuring continuity of care. The
PCP serves not only as the gatekeeper, but as the gate opener to health
care services…" Pennsylvania RFP, pages 1-2.
"G. DIFFERENTLY
ACCESSED SERVICES...
The PCP is
responsible for locating, coordinating, and monitoring all primary care
and other medical and rehabilitation services on behalf of members.
The PCP must furnish primary care to members who are enrolled with them, and serve as gateopeners and gatekeepers for access to most other types of services, with the exception of vision care, dental care, the first prenatal visit to an appropriate specialist, such as an OB/GYN or nurse midwife, and family planning services…" Pennsylvania RFP, page 49.
"I. PROVIDER
NETWORK...
3. Primary
Care Practitioners (PCPs)
a. PCP Responsibilities...
The PCP must
serve as the member's initial and most important point of contact regarding
health care needs. As such, PCP responsibilities must include at a minimum:
• Providing
primary and preventive care and acting as the patient's advocate, providing,
recommending, and arranging for care.
• Maintaining
continuity of each member's health care.
• Making
referrals for specialty care and other medically-necessary services, both
in and out-of-plan.
• Maintaining
a current medical record for the member, including documentation of all
services provided to the member by the PCP, as well as any specialty or
referral services…" Pennsylvania RFP, pages 63-65.
PABH
"2. Coordination
of Care
a.
The MCO and the HealthChoices HMOs are required to develop and maintain
written agreements regarding the interaction and coordination of services
provided to recipients enrolled in the HealthChoices program…The written
agreements should include, but not be limited to: ...
3)
Exchange of relevant enrollment and health-related information among the
MCO, the HMO, and primary care practitioner (PCP in accordance with federal
and state confidentiality laws and regulations; (e.g., periodic treatment
updates with identified primary and relevant specialty providers)...
b.
The MCO must ensure through its provider contracts that its providers interact
and coordinate services with the HMO/PCP in the project area.
Both
behavioral health clinicians and PCPs have the obligation to coordinate
care of mutual patients. Consistent with state and federal confidentiality
laws and regulations, both must:
1)
Ascertain the member's PCP or behavioral health clinician and obtain applicable
releases to share clinical information.
2)
Make referrals for social, vocational, education, or human services when
a need for such service is identified through assessment.
3)
Provide health records to each other, as requested.
4)
Comply with the agreement between the MCO and HMO to assure coordination
between behavioral and physical health care including resolution of any
clinical dispute.
5)
Be available to each other for consultation." Pennsylvania
Behavioral Health RFP, pages 50-51.
"f. The MCO must work in partnership with the designated county municipal health department, and primary care practitioner as applicable, to ensure that conditions identified in accordance with Chapter 25, Disease Prevention and Control Law are reported (e.g., tuberculosis, hepatitis)." Pennsylvania Mental health RFP, page 60.
"b. The
MCO must among the provider network through contracts which include the
following provisions: ...
8)
Requirements for coordination and continuity of care with HMOs and PCPs…"
Pennsylvania Behavioral Health RFP, page 62.
RI
"ARTICLE I:
DEFINITIONS...
1.22
PRIMARY CARE PROVIDER (PCP)
Primary Care
Provider means the individual Plan Physician or team selected by, or assigned
to the member to provide and coordinate all of the member's health care
needs and to initiate and monitor referrals for specialized services when
required..." Rhode Island RFP, pages 1, 4.
"2.08.02
Primary Care Providers (PCP)s
2.08.02.01
PCP Responsibilities
Contractor
agrees to have written policies and procedures for assigning every member
to primary care provider (PCP), who has not chosen one at the time of enrollment.
The PCP must serve as the member's initial and most important point of
interaction with the Health Plan network. As such, PCP responsibilities
must include at a minimum:
- Serving
as the member's primary care provider
- Making
referrals for specialty care and other medically necessary services, both
in-and out-plan
- Maintaining
a current medical record for the member
- Adhering
to the EPSDT periodicity schedule for members under age 21
- Referring
members for case management services
Although PCPs must be given responsibility for the above activities, Contractor also agrees to retain responsibility for monitoring PCP actions to ensure they comply with the Contractor and RIte Care program policies...
2.08.02.03
PCP Teams
If Contractor
primary care network includes institutions with accredited primary care
residency training programs, it may use PCP teams, comprised of residents
and a supervising faculty physician, to serve as a PCP. Contractor
shall organize its PCP teams so as to ensure continuity of care to members
an must identify a 'lead physician' within the team for each member.
The 'lead physician' must be an attending physician and the physician who
is accountable as the PCP. Teams shall be small in size and team
members shall be assigned for sufficient duration to maintain patient continuity.
2.08.02.04
PCP Sites
If Contractor's
primary care network includes Federally Qualified Health Centers (FQHCs)
or Rural Health Centers (RHCs), it may designate either type of site as
a PCP. In both instances, Contractor shall organize it PCP sites
so as to ensure continuity of care to members and shall identify a 'lead
physician' within the site for each member and the physician who is accountable
as the PCP..." Rhode Island RFP, pages 32-34.
SC
"4.8.3
Contractor's Network Composition...
4.8.3.1
Primary Care Providers (PCP)
A PCP in the
Medicaid HMO Program must be a physician or network provider/subcontractor
who provides or arranges for the delivery of medical services, including
case management, to assure that all services which are found to be medically
necessary are made available in a timely manner as outlined in § 4
of this Contract...
The PCP shall serve as the member's initial and most important point of interaction with Contractor's provider network. The PCP responsibilities shall include, at a minimum:
4.8.3.1.1
Managing the medical and health care needs of members to assure that all
medically necessary services are made available in a timely manner;
4.8.3.1.2
Monitoring and follow-up on care provided by other medical service providers
for diagnosis and treatment;
4.8.3.1.3
Providing the coordination necessary for the referral of patients to specialists
and for the referral of patients to services that may be available through
fee-for-service Medicaid.
4.8.3.1.4
Maintaining a medical record of all services rendered by the PCP and other
referral providers." South Carolina Contract, pages 24-25.
"Primary Care Provider (PCP) - The provider who serves as the entry point into the health care system for the member. The PCP is responsible for including, but not limited to providing primary care coordinating and monitoring referrals to specialist care, authorizing hospital services, and maintaining the continuity of care." South Carolina Contract, Appendix A, page 7.
TN
"Attachment
I - Definitions...
40. Primary
Care Physician - a physician responsible for supervising, coordinating,
and providing initial and primary care to patients; for initiating referrals
for specialist care; and for maintaining the continuity of patient care.
41. Primary Care Provider - a primary care physician or registered professional nurse or physician assistant practicing in accordance with state law who is responsible for supervising, coordinating, and providing initial and primary care to patients; for initiating referrals for specialist care; and for maintaining the continuity of patient care…" Tennessee Contract, pages 90-95.
TX
"Primary care physician or primary care provider (PCP) means a physician or provider who has agreed with HMO to provide a medical home to Members and who is responsible for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referral for care (also see Medical home)." Texas Contract, page 10.
"6.6 BEHAVIORAL
HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS…
6.6.7
HMO must require, through contract provisions, that PCPs have screening
and evaluation procedures for detection and treatment of, or referral for,
any known or suspected behavioral health problems and disorders.
PCPs may provide any clinically appropriate behavioral health care services
within the scope of their practice. This requirement must be included
in all Provider Manuals.
6.6.8 HMO must require that behavioral health providers refer Members with known or suspected physical health problems or disorders to their PCP for examination and treatment. Behavioral health providers may only provide physical health care services if they are licensed to do so. This requirement must be included in all Provider Manuals." Texas Contract, pages 38-39.
"7.8 PRIMARY
CARE PROVIDERS…
7.8.11
HMO must require PCPs, through contract provisions or provider manual,
to provide primary care services and continuity of care to Members who
are enrolled with or assigned to the PCP. Primary care services are
all services required by a Member for the prevention, detection, treatment
and cure of illness, trauma, disease or disorder, which are covered and/or
required services under this contract. All services must be provided
in compliance with generally accepted medical and behavioral health standards
for the community in which services are rendered. HMO must require
PCPs, through contract provisions or provider manual, to provide children
under the age of 21 services in accordance with the American Academy of
Pediatric recommendations and the THSteps periodicity schedule and provide
adults services in accordance with the U.S. Preventive Services Task Force’s
publication 'Put Prevention Into Practice.'
7.8.11.1 HMO must require PCPs, through contract provisions or provider manual, to assess the medical needs of Members for referral to specialty care providers and provide referrals as needed. PCP must coordinate care with specialty care providers after referral.
7.8.11.2 HMO must require PCPs, through contract provisions or provider manual, to make necessary arrangements with home and community support services to integrate the Member’s needs. This integration may be delivered by coordinating the care of Members with other programs, public health agencies and community resources which provide medical, nutritional, behavioral, educational and outreach services available to Members.
7.8.11.3 HMO must require, through contract provisions or provider manual, that the Member’s PCP or HMO provider through whom PCP has made arrangements, be the admitting or attending physician for inpatient hospital care, except for emergency medical or behavioral health conditions or when the admission is made by a specialist to whom the Member has been referred by the PCP. HMO must require, through contract provisions or provider manual, that PCP assess the advisability and availability of outpatient treatment alternatives to inpatient admissions. HMO must require, through contract provisions or provider manual, that PCP provide or arrange for pre-admission planning for non-emergency inpatient admissions, and discharge planning for Members. PCP must call the emergency room with relevant information about the Member. PCP must provide or arrange for follow-up care after emergency or inpatient care.
7.8.11.4 HMO must require PCPs for children under the age of 21 to provide or arrange to have provided all services required under Article 6.8 relating to Texas Health Steps, Article 6.9 relating to Perinatal Services, Article 6.10 relating to Early Childhood Intervention, Article 6.11 relating to WIC, Article 6.13 relating to People With Disabilities or Chronic or Complex Conditions, and Article 6.14 relating to Health Education and Wellness and Prevention Plans. PCP must cooperate and coordinate with HMO to provide Member and the Member’s family with knowledge of and access to available services." Texas Contract, pages 63, 65-66.
UT
"Q. 'Primary Care Provider' or 'PCP'... PCPs are responsible for delivering primary care services, coordinating and managing Enrollees' overall health and, authorizing referrals for other necessary care." Utah Contract, Attachment B, pages 2-3.
"8. Mental
Health Services
When
an Enrollee presents with a possible mental health condition to his or
her CONTRACTOR primary care physician, it is the responsibility of the
primary care provider to determine whether the Enrollee should be referred
to a psychologist, pediatric specialist, psychiatrist, neurologist, or
other specialist..." Utah Contract, Attachment B, page 22.
UTMH
"7. Coordination
- The CONTRACTOR will provide access to a coordinated, comprehensive, and
continuous array of needed services through coordination with other appropriate
entities.
a.
Medicaid Prepaid Mental Health Plan (PMHP) Enrollees may also be enrolled
in another managed care plan, such as an HMO or primary care physician
program, that will be responsible for directing the physical health needs
of the individual. The CONTRACTOR will coordinate the provision of
covered mental health services with the Enrollee's HMO or primary care
physician...
b.
The CONTRACTOR will educate HMOs and primary care physicians on the diagnosis,
treatment, and referral of behavioral health disorders commonly seen in
primary care." Utah Mental Health Contract, page 11.
VA
"ARTICLE I -
DEFINITIONS...
Primary Care
Provider (PCP) - A practitioner who provides preventive and primary medical
care for eligible Medicaid and CMSIP recipients, and who certifies prior
authorizations and referrals for all medically necessary specialty services…"
Virginia Contract, pages 7-11.
WA
"1.13 Primary Care Provider (PCP) means a participating medical provider who has the responsibility for supervising, coordinating, and providing primary health care to members, initiating referrals for specialist care, and maintaining the continuity of member care…" Washington General Services, page 3
WV
"1. DEFINITIONS
As used throughout
this contract, the following terms shall have the meanings set forth below...
Primary Care Provider (PCP) - a specific clinician responsible for coordinating the health care needs of certain enrollees…" West Virginia Contract, pages 4-5.
"3.2.1
PCP Responsibilities
The PCP will
be the MCP enrollee's initial and most important contact with the MCP.
As such, PCPs must have at least the following responsibilities:
a) Maintaining
continuity of each enrollee's health care by serving as the enrollee's
primary care provider;
b) Providing
24-hour, seven day a week access;
c) Making
referrals for specialty care and other medically necessary services, both
in-plan and out-of-plan;
d) Maintaining
a current medical record for the enrollee, including documentation of all
services provided to the enrollee by the PCP, as well as any specialty
or referral services;
e) Adhering
to the EPSDT periodicity schedule for enrollees under age twenty-one (21);
and
f) Following
MCP established procedures for coordination of in-network and out-of-network
services for Medicaid enrollees." West Virginia RFA, page 15.