Common use of PCP Assignment Clause in Contracts

PCP Assignment. a. In the event that the Contractor is unable to elicit a PCP selection from an Enrollee, the Contractor shall promptly assign a PCP to each such Enrollee as described below. Such assignment shall be to the most appropriate PCP in accordance with this Contract and EOHHS policies and shall be effective no later than 15 days after the Effective Date of Enrollment in the Contractor’s Plan. b. The Contractor shall, at a minimum, determine whether the assigned Enrollee has received services under the Contractor’s Plan within the previous year under MassHealth or a commercial membership. 1) If the assigned Enrollee was previously enrolled with the Contractor’s Plan, then the assignment shall be to the Enrollee’s most recent PCP if, in the Contractor’s reasonable judgment, such assignment is appropriate. 2) If the assigned Enrollee was not previously enrolled with the Contractor’s Plan, then the Contractor shall make its best efforts to seek and obtain pertinent information from the Enrollee to assign the Enrollee to an appropriate PCP, considering all sources of information available to the Contractor, including but not limited to, information provided by EOHHS or its CSC Enrollment Vendor. The Contractor shall, based on such information that it is able to obtain in a timely manner, take into account factors that include, but are not limited to, the following: a) Available information on the Enrollee’s health care needs, including Behavioral Health Services needs; b) PCP training and expertise with demographic or special populations similar to the Enrollee, including children in the care or custody of DCF or youth affiliated with DYS (either detained or committed) and homeless persons; c) Geographical proximity of PCP site(s) to the Enrollee’s residence; d) Whether the PCP site is accessible by public transportation; e) Whether the PCP site is accessible to people with disabilities; f) The Enrollee’s preferred language and capabilities of the PCP to practice in that language; and g) Access to skilled medical interpreters who speak the Enrollee’s preferred language at the PCP site. c. The Contractor shall inform the Enrollee of the name of the PCP to whom he or she is assigned and offer to assist the Enrollee in scheduling an initial appointment with the PCP. d. The Contractor shall routinely and promptly inform PCPs of newly assigned Enrollees and shall require PCPs to make best efforts to schedule an initial appointment with new Enrollees. e. The Contractor shall submit to EOHHS for its review and prior approval, a model assignment notification letter for Enrollees and an assignment notice for PCPs. f. For any Enrollee who has not yet selected or been assigned a PCP, the Contractor shall, within three business days after receiving notification that such Enrollee seeks to or has obtained care, in or out of the Contractor’s Provider Network, contact the Enrollee and assist the Enrollee in choosing a PCP. If the Contractor is unable to reach the Enrollee, then the Contractor shall assign a PCP to such Enrollee and affirmatively notify the Enrollee of the assignment.

PCP Assignment. a. In the event that the Contractor is unable to elicit a PCP selection from an Enrollee, the Contractor shall promptly assign a PCP to each such Enrollee as described below. Such assignment shall be to the most appropriate PCP in accordance with this Contract and EOHHS policies and shall be effective no later than 15 days after the Effective Date of Enrollment in the Contractor’s Plan. b. . The Contractor shall, at a minimum, determine whether the assigned Enrollee has received services under the Contractor’s Plan within the previous year under MassHealth or a commercial membership. 1) If the assigned Enrollee was previously enrolled with the Contractor’s Plan, then the assignment shall be to the Enrollee’s most recent PCP if, in the Contractor’s reasonable judgment, such assignment is appropriate. 2) If the assigned Enrollee was not previously enrolled with the Contractor’s Plan, then the Contractor shall make its best efforts to seek and obtain pertinent information from the Enrollee to assign the Enrollee to an appropriate PCP, considering all sources of information available to the Contractor, including but not limited to, information provided by EOHHS or its CSC Enrollment Vendor. The Contractor shall, based on such information that it is able to obtain in a timely manner, take into account factors that include, but are not limited to, the following: a) Available information on the Enrollee’s health care needs, including Behavioral Health Services needs; b) PCP training and expertise with demographic or special populations similar to the Enrollee, including children in the care or custody of DCF or youth affiliated with DYS (either detained or committed) and homeless persons; c) Geographical proximity of PCP site(s) to the Enrollee’s residence; d) Whether the PCP site is accessible by public transportation; e) Whether the PCP site is accessible to people with disabilities; f) The Enrollee’s preferred language and capabilities of the PCP to practice in that language; and g) Access to skilled medical interpreters who speak the Enrollee’s preferred language at the PCP site. c. . The Contractor shall inform the Enrollee of the name of the PCP to whom he or she is assigned and offer to assist the Enrollee in scheduling an initial appointment with the PCP. d. . The Contractor shall routinely and promptly inform PCPs of newly assigned Enrollees and shall require PCPs to make best efforts to schedule an initial appointment with new Enrollees. e. . The Contractor shall submit to EOHHS for its review and prior approval, a model assignment notification letter for Enrollees and an assignment notice for PCPs. f. . For any Enrollee who has not yet selected or been assigned a PCP, the Contractor shall, within three business days after receiving notification that such Enrollee seeks to or has obtained care, in or out of the Contractor’s Provider Network, contact the Enrollee and assist the Enrollee in choosing a PCP. If the Contractor is unable to reach the Enrollee, then the Contractor shall assign a PCP to such Enrollee and affirmatively notify the Enrollee of the assignment.