PCP Responsibilities. The PCP will be the MCO enrollee’s initial and most important contact with the MCO. As such, PCPs must have at least the following responsibilities: • Maintaining continuity of each enrollee’s health care by serving as the enrollee’s primary care provider; • Providing twenty-four (24)-hour, seven (7)-day-a-week access; • Making referrals for specialty care and other Medically Necessary covered services, both in-network and out-of-network, consistent with the MCO’s utilization management policies; • 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; • Adhering to the EPSDT Periodicity Schedule for enrollees under age twenty-one (21); and • Following MCO-established procedures for coordination of in-network and out-of- network services for Medicaid enrollees. Although PCPs must be given responsibility for the above activities, the MCO must also retain responsibility for monitoring PCP actions to ensure they comply with MCO and West Virginia Medicaid managed care program policies. Additionally, the MCO must communicate with PCPs about the delivery of primary behavioral health services within their scope of practice, as well as the appropriate circumstances for making referrals to behavioral health providers. MCOs may provide this information through its provider manual, continuing education agendas, informal visits by provider representatives, or any other means. The MCO must ensure that PCPs are successfully identifying and referring patients to a behavioral health provider and provide education to PCPs who do not have training in this area.
PCP Responsibilities. PCPs will be the MCO enrollee’s initial and most important contact with the Medicaid MCO. The PCPs’ responsibilities are outlined in Article III, Section 2.2 of the contract.
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.
PCP Responsibilities. The Contractor shall require PCPs to meet the following requirements:
1. PCPs who serve Members under the age of nineteen (19) are responsible for conducting all Well-Baby and Well-Child Care services. Should the PCP be unable to conduct the necessary Well-Baby and Well-Child Care services screens, the PCP is responsible for arranging to have the necessary Well-Baby and Well-Child Care services screens conducted by another network Provider and ensure that all relevant medical information, including the results of the Well-Baby and Well-Child Care services screens, are incorporated into the Member’s PCP Medical Record
2. PCPs who serve Members under the age of nineteen (19) report encounter data associated with Well-Baby and Well-Child Care services, using a format approved by the Division, to the Contractor within one hundred eighty (180) calendar days from the date of service.
3. PCPs are responsible for contacting new Members identified in the quarterly encounter lists sent by the Contractor that indicate who has not had an encounter during the first six (6) months of Enrollment. The Contractor must require the PCP to:
a. Contact Members identified in the quarterly Encounter lists as not complying with Well-Baby, Well-Child Care, and immunization schedules for Children;
b. Identify to the Contractor any such Members who have not come into compliance with Well-Baby, Well-Child Care, and immunization schedules within one (1) month of such notification to the site by the Contractor; and
c. Document the reasons for noncompliance, where possible, and to document its efforts to bring the Member's care into compliance with the standards.
4. Specialists as PCPs Members with disabling conditions, chronic conditions, or with special health care needs may request that their PCP be a specialist. The designation of a specialist as a PCP must be pursuant to a treatment plan approved by the Contractor; in consultation with the PCP to which the Member is currently assigned, the Member and, as appropriate, the specialist. When possible, the specialist must be a Provider participating in the Contractor’s network. The specialist as a PCP must agree to provide or arrange for all primary care, including routine preventive care, and to provide those specialty medical services consistent with the Member’s disabling condition, chronic illness, or special health care need in accordance with the Contractor’s standards and within the scope of the specialty training and clinical ex...
PCP Responsibilities. 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 (PCP) and medical home • Willing and able to provide the level of care and range of services necessary to address the medical and behavioral needs of members, including those members with chronic conditions • Provide overall clinical direction and serve as the central point for the integration and coordination of care • Making referrals for specialty care and other Medically Necessary services, both in- and out-of-plan • Maintaining and sharing a current medical record for the member in accordance with professional standards and encouraging the member to participate in Current Care • Serve as the general care manager and refer members for specialized care management services, when appropriate Although PCPs must be given responsibility for the above activities, the Contractor also agrees to retain responsibility for monitoring PCP actions to ensure they comply with the Contractor and Medicaid managed care program policies.
PCP Responsibilities. Other Provider or Subcontractor responsibilities;
PCP Responsibilities. PCPs will be the MCO enrollee’s initial and most important contact with the Medicaid MCO. The PCPs’ responsibilities are outlined in Article III, Section 2.2 of the contract. According to West Virginia State Code 16-29 H-9, a patient-centered medical home is, “a health care setting that facilitates partnerships between individual patients and their personal physicians and, when appropriate, the patients’ families and communities. A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician or physician practice that leads a multidisciplinary health team, which may include, but is not limited to, nurse practitioners, nurses, physician’s assistants, behavioral health providers, pharmacists, social workers, physical therapists, dental and eye care providers and dieticians to meet the needs of the patient in all aspects of preventive, acute, chronic care and end-of-life care using evidence-based medicine and technology. At the point in time that the Center for Medicare and Medicaid Services includes the nurse practitioner as a leader of the multidisciplinary health team, this state will automatically implement this change.”
PCP Responsibilities. If applicable, and Provider is a PCP, Provider shall comply with the following:
3.4.1 PCPs who serve Members under the age of nineteen (19) are responsible for conducting all Well- Baby and Well-Child Care services. Should the PCP be unable to conduct the necessary Well-Baby and Well-Child Care services screens, the PCP is responsible for arranging to have the necessary Well-Baby and Well-Child Care services screens conducted by another network provider and ensure that all relevant medical information, including the results of the Well-Baby and Well-Child Care services screens, are incorporated into the Member’s PCP Medical Record.
3.4.2 PCPs who serve Members under the age of nineteen (19) report encounter data associated with Well-Baby and Well-Child Care services, using a format approved by DOM, to Contractor within one hundred and eighty (180) calendar days from the date of service.
3.4.3 PCPs are responsible for contacting new Members identified in the quarterly encounter lists sent by Contractor that indicate who has not had an encounter during the first six (6) months of Enrollment. Contractor must require the PCP to:
3.4.3.1 Contact Members identified in the quarterly Encounter lists as not complying with Well-Baby, Well-Child Care, and immunization schedules for Children;
3.4.3.2 Identify to Contractor any such Members who have not come into compliance with Well-Baby, Well-Child Care, and immunization schedules within one (1) month of such notification to the site by Contractor; and
3.4.3.3 Document the reasons for noncompliance, where possible, and to document its efforts to bring the Member's care into compliance with the standards.
3.4.4 PCP shall provide the full range of Well-Baby, Well-Child Care, well-adolescent care and childhood and adolescent immunization services recommended by the Advisory Committee on Immunization Practices (ACIP) for all Members under the age of nineteen (19) as defined in, and in accordance with, the State Child Health Plan, 42 C.F.R. §457.495 and the provisions of Mississippi CHIP Contract, including periodic examinations for vision, dental, and hearing and all Medically Necessary services. The following minimum elements must be included in the periodic health screening assessment of children:
a. Comprehensive health and development history (including assessment of both physical and mental development);
b. Measurements (including head circumference for infants);
c. Comprehensive unclothed physical examination;
d. I...
PCP Responsibilities. Contractor agrees to have written policies and procedures for assigning every member to a 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 (PCP) and medical home • Provide overall clinical direction and serve as the central point for the integration and coordination of 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 • Serve as the general care manager and refer members for specialized care management services, when appropriate 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 Contractor and Rhode Island Medical Assistance managed care program policies.
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
