Choice of a Network Provider. The Contractor shall offer each Member the opportunity to choose from at least two (2) network Primary Care Providers (PCPs). If the Member does not voluntarily choose a PCP, the Contractor may assign the Member a PCP. A Member who has received Prior Authorization from the Contractor for referral to a specialist or from the Division’s vendor for inpatient care shall be allowed to choose from among all the available specialists and hospitals within the Contractor’s network to the extent possible, reasonable, and appropriate. The Contractor is responsible for assigning Members to PCPs to serve as Medical Homes and must have written policies and procedures for assigning Members to PCPs. The Contractor must submit PCP assignment policies and procedures to the Division for review and approval upon contract award and must also submit any updates. Any changes or modifications to these policies and procedures must be submitted by the Contractor to the Division at least thirty (30) calendar days prior to implementation and must be approved by the Division. These policies and procedures shall include the features listed below:
Choice of a Network Provider. The Contractor shall offer each Member the opportunity to choose from at least two (2) network Primary Care Providers (PCPs). If the Member does not voluntarily choose a PCP, the Contractor may assign the Member a PCP. A Member who has received Prior Authorization from the Contractor for referral to a specialist or from the Division’s vendor for inpatient care shall be allowed to choose from among all the available specialists and hospitals within the Contractor’s network to the extent possible, reasonable, and appropriate. The Contractor is responsible for assigning Members to PCPs to serve as Medical Homes and must have written policies and procedures for assigning Members to PCPs. The Contractor must submit PCP assignment policies and procedures to the Division for review and approval upon contract award and must also submit any updates. Any changes or modifications to these policies and procedures must be submitted by the Contractor to the Division at least thirty (30) calendar days prior to implementation and must be approved by the Division. These policies and procedures shall include the features listed below:
1. Providers Qualifying as Primary Care Providers (PCP): The following types of specialty Providers may perform as Primary Care Providers:
a. Pediatricians;
b. Family and General Practitioners;
c. Internists;
d. Obstetrician/Gynecologists;
e. Nurse Practitioners (contracted nurse practitioners acting as PCPs must have a formal, written collaborative/consultative relationship with a licensed physician with admitting privileges at an inpatient hospital facility or have a written agreement with a physician who has admitting privileges at a hospital appropriate for the patient needing admission);
f. Physician Assistants;
g. Specialists who perform primary care functions upon request; or
h. Other Providers approved by the Division. (e.g., surgeons, clinics, including but not limited to Federally Qualified Health Centers, Rural Health Clinics, Health Departments, and other similar community clinics).
i. If applicable, for Members who qualify under the rural resident exception, (under which the Division may limit a rural area resident to a single Contractor), the limitation on the Member’s freedom to change between Primary Care Providers can only be as restrictive as the limitations on Member-requested Disenrollment.
