"23. OTHER
PROVIDER STANDARDS…
For specialty
services, the Contractor shall ensure that: ...
b.
Specialty physicians shall not begin a course of treatment for a medical
condition other than that for which the member was referred, unless approved
by the member’s PCP.
c.
The specialty physicians shall provide to the member’s PCP complete documentation
of all diagnostic services including copies of test results if applicable,
treatment services provided and the resulting outcome for each.
Members may choose, or be assigned, a PCP who provides obstetric care (physician or certified nurse midwife)...
All physicians and certified nurse midwives who perform deliveries shall have OB hospital privileges. Licensed midwives perform deliveries only in the member’s home. Labor and delivery services may also be provided in the member’s home by physicians and certified nurse practitioners and certified nurse midwives who include such services within their practice." Arizona Contract, pages 32-33.
AZBH
"14. COORDINATION
WITH AHCCCS ACUTE CARE CONTRACTORS
ADHS and its
subcontracted RBHAs are responsible for coordination of care with the AHCCCS
acute care contractors. ADHS shall establish policies and procedures
for ensuring implementation and monitoring of communication and coordination
between acute care and behavioral health contractors and subcontracted
RBHAs...
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." Arizona
Behavioral Health Contract, pages 18-19.
IL
"(D) The Contractor shall require its Primary Care Providers and Women's Health Care Providers to… arrange appropriate referral to physician specialist… the Contractor shall utilize, for such high risk consultation or referrals, the standards of care promulgated by the Statewide Perinatal Program or the Illinois Department of Human Services." Illinois HMO Contract, page 43.
IABH
"IV. Mental
health Services...
C. Service
Coordination and treatment Planning (Proposal Section)
Upon request,
MBC of Iowa can provide consultation to Iowa Plan providers. Through
the MBC of Iowa physician review network (available 24 hours a day), psychiatrists
who are Board Certified in Child and Adolescent Psychiatry, psychiatrists
with specialties in eating disorders, bipolar disorders, etc are available
for case consultation…" Iowa Behavioral Health Contract, page 58.
KY
"Specialty providers may serve as PCPs under certain circumstances, depending on the members' needs. For example, the PCP for a Member with gynecological or obstetrical health care needs, disabilities or complex, chronic conditions may be a specialist who is willing to provide or arrange for all appropriate primary and preventive care, including 24 hour access, either directly or through linkage with a PCP." Kentucky RFA, page 44.
MD
"10.09.64.10...
.10 Special
Needs Populations.
An MCO applicant
shall include in its application the following information and descriptions:
...
C. Written
evidence, including treatment protocols, of the applicant's ability to
provide the range of clinical and support services specified in COMAR 10.09.65.05-.11,
to ensure appropriate and coordinated services to the following special
populations:
(1) Children
with special health care needs,
(2) Individuals
with a physical disability,
(3) Individuals
with a developmental disability,
(4) Pregnant
and postpartum women,
(5) Individuals
who are homeless,
(6) Individuals
with HIV/AIDS, and
(7) Individuals
in need of substance abuse treatment…" Maryland COMAR 10.09.64.10.
MI
"II-M CONTRACTOR
ORGANIZATIONAL STRUCTURE, ADMINISTRATIVE SERVICES, FINANCIAL REQUIREMENTS
AND PROVIDER NETWORKS...
6. Provider
Network in the CHCP...
(i) PCP Standards...
The Contractor
will allow a specialist to perform as a PCP when the Enrollee's medical
condition warrants management by a physician specialist. This may
be necessary for those Enrollees with conditions such as diabetes, end-stage
renal disease or other chronic decease or disability of disability…"
Michigan Contract, pages 32, 35, 39.
MO
"b. Eligible Specialties: The health plan must agree to limit its primary care providers to licensed residents specializing in family and general practice, pediatrics, obstetrics and gynecology, and internal medicine; registered nurses who are advanced practice nurses with specialties in family practice, pediatric practice, and obstetric and gynecology practice; and licensed physicians in the following specialties: family and general practitioners, pediatricians, obstetricians and gynecologists (OB/GYN) and internists. The state agency strongly encourages the health plan to include all of these specialties in its primary care provider network…
"f. Mental Health In-Network Self Referrals: Each plan shall describe the protocols for coordinating care between primary care providers and behavioral health providers and indicate the expected response time for consults between behavioral health and in-network providers." Missouri Contract, page 26." Missouri RFP, page 24.
NE
"4.1.13 The term 'Designated Specialty Care Physician' means a specialty care physician who has enhanced functions for clients with special health care needs designated, upon review and concurrence, by the Primary Care Physician (PCP), the specialist and the plan. The designation of the specialty care physician allows for greater continuity of care between the PCP and specialty care physician, such as open referrals, shared PCP responsibilities, etc." Nebraska Contract, page 8.
NEBH
"11.11.3 MH/SA
Provider Qualifications and Responsibilities: Pursuant to the PHP’s contractual
responsibilities, the PHP shall ensure that the MH/SA provider complies
with the following: ...
(b) Signing
a contract with the PHP as a MH/SA provider which explains the provider’s
responsibilities and compliance with the following NHC requirements: ...
(4) As appropriate, working cooperatively with specialists, consultative
services and other facilitated care situations for special needs clients,
e.g., deaf and hard of hearing, persons with dual-diagnosis, etc…"
Nebraska Behavioral Health Contract, pages 54-55.
NM
"2.A.5
Referral and Coordination
The CONTRACTOR
shall have and comply with written policies and procedures for the coordination
of care and the arrangement, tracking, and documentation of all referrals
including referrals to the following providers: … other specialists...
The CONTRACTOR's policies and procedures shall ensure that referrals including
referrals to the following providers: …other specialists...for medically
necessary services are available to members…" New Mexico Contract,
page 15.
OR
"O. Cooperation
with Residential Nursing Facilities and Foster Care & Group Homes
Contractor
shall assist, as appropriate, residential and nursing facilities and foster
care and group homes to comply with all Oregon Administrative Rules that
pertain to provision of Capitated Services including, but not limited to:
OARs 309-40-052, 309-41-630, 309-41-780, 309-49-075, 309-49-175, 411-50-447,
411-55-170, 411-55=180, 411-56-015, and 411-86-200 through 300."
Oregon Contract, page 12.
SC
"4.8.4
Specialty Providers...
Specialty Provider
responsibilities shall include at a minimum:
4.8.4.1
Providing consultation summaries or appropriate periodic progress notes
to the member's primary care provider on a timely basis, following a referral
or routinely scheduled consultative visit;
4.8.4.2
Notifying the member's primary care provider when scheduling a hospital
admission or any other procedure requiring the primary care provider's
approval…" South Carolina Contract, pages 25-26.
TX
"7.10
SPECIALTY CARE PROVIDERS...
7.10.2
HMO must require, through contract provisions or provider manual, that
specialty providers send a record of consultation and recommendations to
a Member’s PCP for inclusion in Member’s medical record and report encounters
to the PCP and/or HMO." Texas Contract, page 67."