PCPs. 9.6.1.1 The Contractor shall establish a system of coordinated care in which the Primary Care Physician (PCP), will be part of a Primary Medical Group (PMG). PCPs will be responsible for providing, managing and coordinating all the services of the Enrollee, including the coordination with behavioral health personnel, in a timely manner, and in accordance with the guidelines, protocols and practices generally accepted in medicine.
9.6.1.2 The PCP is responsible for maintaining each Enrollee’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services, which may be maintained through a certified EHR system meeting the specifications set forth in Attachment 15 to this Contract.
9.6.1.3 The following shall be considered PCPs for purposes of contracting with a PMG:
9.6.1.3.1 General practitioners;
9.6.1.3.2 Internists;
PCPs. Providers who are PCPs shall comply with all additional requirements pertaining to PCPs under the applicable State Contract, including, but not limited to the following:
i) PCPs who serve Medical Assistance Covered Persons under the age of twenty- one (21) years are responsible for conducting all EPSDT screens for individuals on their panel under the age of twenty-one (21). If the PCP is unable to conduct the necessary EPSDT screens, the PCP must arrange to have the necessary EPSDT screens conducted by another Participating Provider and ensure that all relevant medical information, including the results of the EPSDT screens, is incorporated into the Covered Person’s PCP medical record. PCPs must report Encounter Data associated with EPSDT screens to Health Plan or Subcontractor, as directed, using a format approved by DHS, within ninety (90) days from the date of service.
ii) PCPs who serve Medical Assistance Covered Persons under the age of twenty- one (21) years must contact those Covered Persons identified by Health Plan in quarterly Encounter lists as not complying with EPSDT periodicity and immunization schedules for children and shall identify to Health Plan or Subcontractor, as directed, any such Covered Persons who have not come into compliance with the EPSDT periodicity and immunization schedules within one
(1) month of notification to the PCP by Health Plan or Subcontractor of noncompliance. PCPs shall document the reasons for noncompliance, where possible, and efforts made to bring the Covered Person’s care into compliance with the EPSDT standards.
iii) PCPs shall contact: (a) new Medical Assistance Covered Persons identified by Health Plan in quarterly Encounter lists who have not had an Encounter during the first six (6) months of enrollment with Health Plan or who have not complied with the scheduling requirements under the Medical Assistance State Contract; and (b) all Medical Assistance Covered Persons who have not had an Encounter during the previous twelve (12) months or within the time frames required under the Medical Assistance State Contract.
PCPs. PCPs who have a one-physician practice must have office hours of at least 20 hours per week. Practices with two or more physicians must have office hours of at least 30 hours per week.
PCPs. If Participating Provider is a Primary Care Provider, Participating Provider will: (a) perform, during preventive service visits, and as necessary at any visit, oral health assessments, evaluations, prophylaxis and oral hygiene counseling for children under twenty-one (21) years of age in accordance with the NC DHHS’s Oral Health Periodicity Schedule; (b) refer infant Medicaid Covered Persons to a dentist or a dental professional working under the supervision of a dentist at age one (1), per the requirements of the NC DHHS’s Oral Health Periodicity Schedule; and (c) include all of the following components in each medical screening: (i) routine physical examinations as recommended and updated by the American Academy of Pediatrics (AAP) “Guidelines for Health Supervision III” and described in “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents”, screening for developmental delay at each visit through the 5th year and screening for Autistic Spectrum Disorders per AAP guidelines, (ii) comprehensive, unclothed physical examination, (iii) all appropriate immunizations, in accordance with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices, (iv) laboratory testing (including blood lead screening appropriate for age and risk factors); and (e) health education and anticipatory guidance for both the child and caregiver. (Section V, C.2.i).
PCPs a. The names, addresses, telephone numbers and hospital affiliations of Network PCPs
b. Identification of whether the PCP is a Doctor of Medicine or Osteopathy
c. Identification of whether PCPs are Board-certified and, if so, in what area(s)
d. Identification of PCP Teams which include physicians, Certified Registered Nurse Practitioners (CRNPs), Certified Nurse Midwives and Physician Assistants
e. Identification of languages spoken by Network Providers at the primary care sites
f. Identification of sites which are wheelchair accessible
g. Identification of the days of operation and the hours when the PCP office is available to Members
PCPs. The provider who serves as the entry point into the health care system for the member. The PCP is responsible for to providing primary care, coordinating and monitoring referrals to specialist care, authorizing hospital service and maintaining continuity of care as outlined in §4 of this Contract. The PCP may practice in a solo or group setting or may practice in a clinic (i.e., Federally Qualified Health Center or Rural Health Center) or outpatient clinic. The Contractor shall agree to provide at least one (1) full time equivalent (FTE) PCP per two thousand five hundred (2,500) members (SCHIP Program members and existing commercial members). Each eligible member shall be given the opportunity to choose a specific PCP within the Contractor’s provider network who will be responsible for the provision of primary care services and the coordination of all other health care needs. The Contractor shall assign a PCP to a member if the member fails to select a new PCP within the established timeframe or after a change in PCP has occurred (for example the PCP no longer participating). The Contractor shall submit to SCDHHS a copy of the procedures to be used to contact members for initial member education for approval prior to contract execution. These procedures shall adhere to the enrollment process and procedures outlined in §6 and the post enrollment procedures required in §8 of this Contract. The PCP selected for the member should be a provider that is located geographically close to the member's home, and/or best meets the needs of the member. However, the member has the freedom to request a change of PCP within the time frames and guidelines established by the Contractor. The time frames and guidelines established by the Contractor must not conflict with the Federal rules and regulations governing time frames. The Contractor shall identify to SCDHHS or its designee monthly any PCP approved to provide services under this Contract who will not accept new patients. The PCP responsibilities shall include, at a minimum:
4.9.3.1.1 Managing the medical and health care needs of members to assure that all medically necessary services are made available in a timely manner;
4.9.3.1.2 Providing the coordination necessary for the referral of patients to specialists; and
4.9.3.1.3 Maintaining a medical record of all services rendered by the PCP and other referral providers.
PCPs. The PCP must serve as the CHIP Member’s initial and most important point of contact regarding health care needs. At a minimum, CHIP participating PCPs are responsible for:
5.5.1 Providing primary and preventive care and acting as the CHIP Member’s advocate, providing, recommending, and arranging for care;
5.5.2 Documenting all care rendered in a complete and accurate encounter record that meets or exceeds DHS’s data specifications;
5.5.3 Maintaining continuity of each CHIP Member’s health care, participating in or coordinating with an overall chronic care management team, where appropriate;
5.5.4 Communicating effectively with CHIP Members by using sign language interpreters for those who are deaf or hard of hearing and oral interpreters for a
5.5.5 Making referrals for specialty care and other medically necessary services, both in and out-of-plan;
5.5.6 Maintaining a current medical record for each CHIP Member including documentation of all services provided to the CHIP Member by the PCP, as well as any specialty or referral services;
5.5.7 Arranging for behavioral health services in accordance with CHIP Requirements;
5.5.8 Providing office hours accessible to an enrollee for a minimum of twenty (20) hours per week and directly or through on-call arrangements with other qualified, plan-participating PCPs twenty-four (24) hours per day, seven (7) days a week for urgent and emergency care; and
5.5.9 Complying with all conditions and standards applicable to managed care plans set forth in 40 P.S. §§ 991.2101 – 991.2194 unless otherwise specified. Highmark retains responsibility for monitoring PCP actions to ensure they comply with CHIP Requirements.
PCPs shall:
1. facilitate Conexus delivery of on-site eye exams and glasses (if needed) to PCPS students identified for the program through a failed VisioCheck vision screening;
2. provide written program notification and opt-out opportunities to the students to be screened through VisioCheck;
3. manage program opt-outs;
4. coordinate with Conexus staff to manage the clinic schedule and efficient flow of students; 5. require that a person assigned by the school remain with students during the exam, fitting, and dispensing process;
PCPs. Providers who are PCPs shall comply with all additional requirements pertaining to PCPs under the applicable State Contract, including, but not limited to the following:
i) PCPs who serve Customers under the age of twenty-one (21) years are responsible for conducting all EPSDT screens for individuals on their panel under the age of twenty-one (21). If the PCP is unable to conduct the necessary EPSDT screens, the PCP must arrange to have the necessary EPSDT screens conducted by another Participating Provider and ensure that all relevant medical information, including the results of the EPSDT screens, is incorporated into the Customer’s PCP medical record. PCPs must report Encounter Data associated with EPSDT screens to United, using a format approved by DHS, within ninety (90) days from the date ofservice.
ii) PCPs who serve Customers under the age of twenty-one (21) years must contact those Customers identified by United in quarterly Encounter lists as not complying with EPSDT periodicity and immunization schedules for children and shall identify to United any such Customers who have not come into compliance with the EPSDT periodicity and immunization schedules within one (1) month of notification to the PCP by United of noncompliance. PCPs shall document the reasons for noncompliance, where possible, and efforts made to bring the Customer’s care into compliance with the EPSDT standards.
iii) PCPs shall contact: (a) new Customers identified by United in quarterly Encounter lists who have not had an Encounter during the first six (6) months of enrollment with United or who have not complied with the scheduling requirements under the State Contract; and
PCPs
