Role of primary care providers

GA | IN | IA | MS | MT | NE | NY | NC | ND | OK | SD | VT | VA | WV

GA

"PCPs coordinate their members' health care needs by providing the following services:

  •  Primary care medical services, covered by Medicaid;
  •  Referral authorization for needed specialty and other covered medical services; and
  •  Arranged 24 hour-a-day coverage."  Georgia Agreement, Overview.


    • "802.  Referrals and Authorization Process
    1.  Referrals
    For all Medicaid covered services which PCPs do not provide directly or which are not exempted in Section 803, PCPs must refer to another Medicaid participating provider.  This includes referrals for members to be seen by specialists, hospitals, or other Medicaid enrolled providers.  If the PCP determines that a referral is medically necessary based on the member's diagnosis and medical condition, the PCP must authorize the services by giving an authorization number to the provider...

    901.  General
    The Georgia Better Health Care plan provides a form of coordinated care referred to as primary care case management.  The service delivered under the Georgia Better Health Care plan is the medical case management of the member's health care.  The primary care provider serves as the GBHC case manager and either provides care directly or coordinates the provision of care which may be required, such as a specialty care, dental services for children Health Check services or hospitalizations.  Medicaid covered medical services delivered by PCP are in addition to the case management and are billable as regular Medicaid services.

    The case manager ultimately is responsible for managing the total care provided to GBHC members, serving as the linkage between members and the various services in the health care continuum.  The PCP has specific responsibilities described in the respective policy and procedure manuals for the physician, nurse practitioner, or clinic programs...

    908.1  Authorization of HEALTH CHECK Services
    Effective December 1, 1996, GBHC PCPs are required to authorize referrals for the delivery of HEALTH CHECK services to their GBHC members.  However, immunizations continue to be exempted from the authorization requirement.  The exemption of immunizations from the authorization process does not prevent continued administration of immunizations by the GBHC primary care case managers.

    PCPs have the option of either directly providing HEALTH CHECK services or referring GBHC members to a Medicaid HEALTH CHECK provider.  The Department will provide to GBHC PCPs a monthly listing of their members who are due a HEALTH CHECK screen.  This listing (see Appendix B for sample listing), will include the date the screening is due, the sequence  of screen due and member demographic information.  In addition, members who are due for a HEALTH CHECK screen will be sent a notification letter that includes their GBHC PCP's name, address and telephone number...

    908.3  Authorization For Services Provided Between Routine HEALTH CHECK Sequences
    The PCP may choose to provide medically necessary HEALTH CHECK services between sequences or may refer to another HEALTH CHECK provider.  Interperiodic vision only, hearing only, tuberculin skin test and blood lead test (Savannah lead lab) services may be reimbursed when medically necessary between screening sequences; however, these services must be authorized by or performed by the member's GBHC PCP, utilizing the procedures listed below in order to be reimbursed.  (See Appendix C-2 for sample Request for Services Provided Between Routine HEALTH CHECK Sequences form.)"  Georgia Agreement, pages VIII-1, IX-1, IX-5, IX-7.

    IN

    "General Provisions
    1.  Role of the Primary Medical Provider
    The provider agrees to function in the role of Primary Medical Provider (PMP), as an authorized provider for Hoosier Healthwise Program's Primary Care Case Management provider network.  In this role, the PMP will provide, or will arrange for the provision of, routine comprehensive preventive services, medically necessary primary care treatment and urgent care services, in keeping with the universally accepted standards as defined by Article II, Paragraph 1, of this Addendum.  In particular, the PMP will provide or authorize the following services:

  •  physician services
  •  hospital inpatient and outpatient services
  •  ancillary services including but not limited to:

    • laboratory and radiology; orthotics/prosthetics; Health Watch/EPSDT; audiology; and durable medical equipment and supplies...
    5.  Referral to Other Providers
    The PMP may refer a recipient under his/her care to another Medicaid participating provider for any medically necessary service.  The PMP must document the referral in the recipient's medical record.  An optional sample referral form is included in the Hoosier Healthwise Provider Manual.

    11.  Non-emergency Admissions
    The PMP must approve all non-emergency inpatient admissions."  Indiana Addendum, pages 1, 3-4.

    IA

    "The patient manager agrees to:
    A.  Provide managed health care to all enrolled recipients by providing necessary and appropriate primary health care and providing or referring the patient to other providers of medical care, as medically necessary and appropriate.  Referrals shall occur in accordance with accepted practice in the medical community.  No special referral form is required.  The patient manager is responsible for monitoring and coordinating all such care."  Iowa Agreement, page 1.

    MS

    "4.01  Overview
    Health through Medicaid Managed Access to Care and Services (HealthMACS) is a managed care program in which certain Aid to Families with Dependent Children (AFDC) and AFDC-related Medicaid clients choose and enroll with, or are assigned to, a primary care provider (PCP) who manages their health care needs.  The PCP is responsible for the provision of primary care, appropriate referrals for specialty services, and authorization of specified Medicaid services.  In return for providing case management services, PCPs are paid a monthly case management fee for each client enrollee.  The case management fee is in addition to regular fee-for-service payments...

    4.07 Functions And Duties Of The Primary Care Provider
    Responsibilities of PCPs include the following:
      1.  Provide case management for all Medicaid services that are not excluded from HealthMACS coverage. (See Section 4.08, Medicaid Benefits, for excluded services.)."  Mississippi Manual, pages 71, 76.

    MT

    "I.  GENERAL STATEMENT OF PURPOSE AND INTENT
    The Department contracts with primary care providers participating in the Montana Medicaid Program to provide primary care and management of other health care needs, through appropriate referral and authorization of certain Medicaid services, for recipients who may select or be assigned to the contracting providers...

    This agreement is supplementary to the terms of participation in the provider's Medicaid enrollment form." Montana Agreement, page 1.

    NE

    "1.1.43  The term 'Primary Care Physician (PCP)' means a 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.  A PCP may participate in the NHC with any of the contacting plans.  The PCP shall be a Medicaid enrolled provider.  A specialty care physician may have enhanced functions in certain circumstances, to promote greater continuity of care between the PCP and specialty care physician."  Nebraska Contract, page 8.

    "ARTICLE VII
    7.0 CONTRACTOR RESPONSIBILITIES.  THE PROVISION OF THE BASIC BENEFIT PACKAGE

    7.31.1 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...

    7.7  PCP Qualifications and Responsibilities:  Under the contractual responsibilities of the Contractor, the Contractor shall ensure that the PCP:

       (b)  Sign a contract with the Contractor as a PCP which explains the PCP's responsibilities and compliance with the following NHC requirements;

       (1)  Treat NHC clients in the same manner as other patients;

       (2)  Provide the Basic Benefits Package per 471 to all clients who choose or are assigned to the PCP's practice according to the Enrollment Report and comply with all requirements for referral management, prior authorization and prior approval;

       (3)  Coordinate appropriate referrals when medically necessary to services that typically extend beyond those services provided directly by the PCP, including but not limited to specialty services, emergency room services, hospital services, nursing services, metal health/substance abuse (MH/SA), ancillary services, public health services, and other community based agency services, and ensure that such services are provided by Medicaid enrolled providers;

       (4)  As appropriate, work cooperatively with specialists, consultative services, and other facilitated care situations for special needs clients such as accommodations for the deaf and hard of hearing, experience sensitive conditions such as HIV/AIDS, self referrals for women's health services, family planning services, etc. ...

    The PCP shall coordinate the provision, authorization and the continuity of care, and the Contractor shall monitor overall coordination between these two service areas, i.e., medical/surgical and MH/SA.  The Contractor shall ensure that the PCP is knowledgeable about the MH/SA and other similar services and ensure that appropriate referrals are made to meet the needs of the client;

       (13)  Communicate with agencies including, but not limited to, local public health agencies for the purpose of participating in immunization registries and programs, e.g., Vaccine for Children, communications regarding management of infectious or notifiable diseases, cases involving with lead poisoning, special education programs, early intervention programs, etc.;

       (14)  Comply with all disease notification laws in the State;

       (15)  Provide information to the Department as required;

       (16)  Inform clients about all treatment options, regardless of cost of whether such services are covered by the Nebraska Medical Assistance Program (NMAP); and

       (17)  Provide accurate information to the Contractor in a timely manner, so that PCP information can be exchanged with the Department, via the Provider Network File."  Nebraska Contract, pages 22, 66.

    NY

    "10.15(a)  Adults with Chronic Illnesses and Physical or Developmental Disabilities
    The PCPCP and the PCP/Contractor agrees to implement all of the following to meet the needs of their adult Enrollees with chronic illnesses and physical or developmental disabilities:
    (i)  Satisfactory methods for ensuring compliance with Title II of the Americans with Disabilities Act.

    (ii)  Satisfactory methods/guidelines for identifying persons at risk of, or having, chronic diseases and disabilities and determining their specific needs in terms of specialist physician referrals, durable medical equipment, medical supplies, home health services etc.

    (iii)  Satisfactory case management systems to ensure all required services are furnished on a timely basis.

    (iv)  Satisfactory systems for coordinating service delivery with non-participating providers, including behavioral health providers for all members.

    (v)  Policies and procedures to allow for the continuation of existing relationships with non-participating providers, when considered to be in the best medical interest of the member.

    (vi)  Policies and procedures to allow Enrollees with a life-threatening or degenerative and disabling disease or condition, which requires prolonged specialized medical care to receive a referral to a specialist, who will then function as both the primary care and specialty care provider for that Enrollee.

    (vii)  Policies and procedures to allow Enrollees with a life-threatening or degenerative and disabling disease or condition, which requires prolonged specialized medical care to receive a referral to an accredited or designated specialty care center with expertise in treating the life-threatening or degenerative and disabling disease or condition.

    10.15(b)  Children with Special Health Care Needs
    Children with special health care needs are those who have or are suspected of having a serious or chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. The PCPCP and PCP/contractor will be responsible for performing all of the same activities for this population as for adults.  In addition, the PCPCP and the PCP/Contractor will implement the following for these children:

    (i)  Satisfactory methods for interacting with school districts, preschool services, child protective service agencies, early intervention officials, behavioral health, and developmental disabilities service organizations for the purpose of coordinating and assuring appropriate service delivery.

    (ii)  Assure access to an adequate supply of pediatric providers and sub-specialists, including pediatric HIV practitioners and tertiary institutions, to meet their medical needs.

    (iii)  Satisfactory methods for assuring that children with serious, chronic, and rare disorders receive appropriate diagnostic work-ups on a timely basis.

    (iv)  Satisfactory arrangements for assuring access to specialty centers in and out of New York State for diagnosis and treatment of rare disorders.

    (v)  A satisfactory approach for assuring access to allied health professionals (Physical Therapists, Occupational Therapists, Speech Therapists, and Audiologists) experienced in dealing with children and families...

    10.15(c)  Member Needs Relating to HIV
    The (PCP/Contractor) agrees that anonymous testing may be furnished without prior approval by the (PCP/Contractor) and may be conducted at anonymous testing sites available to clients. Services provided for  HIV treatment may only be obtained from the (PCP/Contractor) if the individual chooses to enroll and stay enrolled with the (PCP/Contractor).

    To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+) individuals who do enroll in managed care, the PCPCP and the (PCP/Contractor) shall have in place all of the following:

    (i) Methods for promoting HIV prevention to all enrollees. HIV prevention information, both primary (targeted to uninfected members), as well as secondary (targeted to those members with HIV) should be tailored to the Enrollee's age, sex, and risk factor(s), including sexual orientation and injection drug use, and must be culturally and linguistically appropriate.  All plan Enrollee's should be informed of the availability of both in-plan HIV counseling and testing services, out-of-plan HIV counseling and testing services when performed as part of a family planning encounter, as well as those available from the New York State, LDSS health unit and New York City operated Anonymous Counseling and Testing Programs.

    (ii) Satisfactory methods for encouraging early entry into treatment.

    (iii) Special attention should be paid to identifying HIV positive (+) women and engaging them in prenatal care in order to promote antiretroviral therapy during pregnancy. The PCPCP and the (PCP/Contractor) shall comply with the HIV Counseling and Testing of Pregnant Women and Newborns as required in Title 10 NYCRR.

    (iv) Satisfactory case management systems to ensure that all necessary services are furnished on a timely basis.

    Special attention should be paid to establishing linkages with traditional HIV providers, such as Aids...

    Contractor must provide all services set forth in the Benefit Package (Appendix L that are covered under the Medicaid fee for service program except for services specifically excluded by the contract, or enacted or effected by Federal or State Law during the period of this agreement...

    17.  MONITORING AND EVALUATION...
    a) The (PCP/PCPCP/Contractor) agrees that Primary Care Providers will serve as each member's initial and most important point of interaction. The (PCP/PCPCP/Contractor) agrees that to qualify as a PCP, a provider must practice at least two days per week (16 hours) at each of his/her 'primary care' sites.

    (b) The (PCP/PCPCP/Contractor) further agrees that in addition to meeting office hour standards, PCPs also must:
    (i) Deliver medically necessary primary care services, including C/THP screening services for children and adolescents and a behavioral health screening for all members, as appropriate.
    (ii) Coordinate each patient's overall course of care.
    (iii) Maintain a current medical record for the member."  New York Contract, pages 29, 30-38, 45-46.

    NC

    "4.5  Provide primary care and patient care coordination services to each enrollee, in accordance with the provisions of this agreement and the policies set forth in the appropriate Medicaid provider manual...

    4.10 Arrange referrals for medically necessary health care services that you do not provide directly and document referrals for specially care in the medical record.  Provide your authorization number (Medicaid Provider number) to the referral provider either in writing or by telephone.

    4.11 Refer for a second opinion if asked to do so by an enrollee when surgery has been recommended; treatment subsequent to the second opinion shall be rendered by the Carolina ACCESS primary care provider."  North Carolina Agreement, page 3.

    ND

     "II.  SCOPE OF SERVICE
    The Contractor agrees to provide health, dental and vision coverage and other services as identified in the State's Request for Proposal and the Contractor's Proposal, included by reference and made a part of this agreement subject to the terms of this Purchase of Service Agreement."  North Dakota Agreement, page 1.

    OK

    "2.2  Responsibilities and Services Provided
    A.  Contractor shall furnish primary care and case management services.  The Contractor shall provide all capitated lab and x-ray services as contained in Attachment 'A' for adults and children without payment in addition to the capitation rate except as otherwise provided in this contract.  Any other services in the service package which cannot be provided by the Contractor in the Contractor's office must be purchased by the Contractor from another provider without payment in addition to the capitation rate except as otherwise provided in this contract."  Oklahoma Agreement, page 6.

    SD

    "2.  Provider agrees to provide comprehensive primary health care services for Medicaid recipients who have been assigned to your practice.  This includes:
    A.  Provider has not been restricted from participating in any private, Federal or State Health Insurance Program.
    B.  Provider has hospital privileges.
    C.  Provider has a current Drug Enforcement Agency (DEA) number to prescribe controlled substances.

    3.  Provider agrees to refer recipients for specialty care, hospital care, and other services only when medically necessary and sign and document referrals.

    4.  Provider agrees to authorize services provided by referred providers if it is determined by the Provider that those services are medically necessary."  South Dakota Provider Agreement, Addendum, page 1.

    VT

    "8.  The PCD will provide all covered primary services consistent with the PCD's qualifications."  Vermont Agreement, page 3.

    VA

    "1.  Function in the role of PCP for MEDALLION.  In this role, Provider will carry out all routine preventative and treatment services to MEDALLION patients assigned to the PCP's practice.  This will include Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services and maintenance of a comprehensive medical record for each patient assigned to the PCP's MEDALLION panel.  In particular, the PCP will provide and/or coordinate patient management for all preventive, primary and specialty health care services.  The PCP must have admitting privileges at a local accredited hospital or must make arrangements for admissions with a physician who does have admitting privileges...

    3.  Coordinate all other Medicaid authorized care for each patient enrolled in his or her MEDALLION caseload including referral to specialty providers for medically necessary services.  In referring for specialized evaluation and/or treatment, the PCP will provide the specialist with authorization to cover appropriate testing and treatment. This authorization may be verbal or written for  a period appropriate to the illness.  The PCP will document all referrals in the patient's medical record."  Virginia Agreement, Appendix A, page A-1.

    WV

    "I.  GENERAL STATEMENT OF PURPOSE AND INTENT:
    The establishment of a health care network by contract with Medicaid participating primary care physicians, groups and clinics to:

  • provide primary care to specified recipients who may select, or be assigned to, the contracting physicians, groups, and clinics.
  • establish and provide for a continuum of care through preventive procedures, education, testing and monitoring of health status.
  • manage other health care needs through appropriate referral and authorization.
    • IV.  IT IS AGREED THAT THE PAAS PHYSICIAN OR CLINIC WILL:  ...

    D. Provide primary care and patient management services to each enrollee, in accordance with the provisions of this agreement, and pursuant to the Medicaid Program's regulations governing the provision of service in the provider's particular setting.

    E. Determine the necessity for and approve, as appropriate, non-emergency care covered under the PAAS program...

    H.  Authorize, as appropriate, treatment for urgent or emergency care in accordance with PAAS provisions as outlined in WVPAAS, Chapter II, 'Emergency Department Services and Physician Back-Up'.

    I. Arrange for a second opinion, if requested by the enrollee, when surgery has been recommended.  Treatment subsequent to the second opinion shall be rendered by the PAAS provider or through a referral by the PAAS provider.

    J. Refer the enrollee to the local health department for immunizations not provided by the PAAS provider.

    K. Maintain a unified patient medical record for each enrollee."  West Virginia PAAS, pages 1, 3.