Common use of Primary Care Network List (PCNL) Clause in Contracts

Primary Care Network List (PCNL). Specifications. The MCO must supply all Local Agencies within its Service Area with copies of a standardized document (known as a Primary Care Network List, or PCNL) that provides information about the MCO’s Medicare and Medicaid Provider network and that includes a description of the essential components of the MCO, to be used by the STATE and Local Agencies to educate consumers. If the MCO also provides its PCNL in alternative format pursuant to section 3.6.9, then the MCO must also supply all Local Agencies within its Service Area with such alternative format. This document must follow the STATE specifications as indicated in the STATE model document entitled “ Primary Care Network List (PCNL) Guidelines: REQUIREMENTS FOR PCNLS” posted on the STATE’s managed care website and must be prior approved by the STATE in accordance with section 3.6.5(A). The document must contain the following information: A list of Network Providers with summary information, which shall include but is not limited to, addresses and phone numbers including clinics, Primary Care physicians, specialists, hospitals, Nursing Facilities, and Care Systems. The MCO may satisfy or partially satisfy the requirement to list specialists by listing multi- specialty clinics. The PCNL must indicate Providers who speak a non-English language and identify Providers that are not accepting new patients within the Service Area at the time the list is prepared. The MCO must also provide information upon request regarding a specific Provider, including specialists, if the Provider is not listed in the PCNL. The MCO may list other affiliated Providers and their addresses or provide a toll-free phone number where a Potential Enrollee may call to obtain the specific information. The information required by this section may be posted on the MCO’s web site but the MCO must continue to provide paper copies to the STATE and the counties. A toll-free telephone number that the Enrollee may contact regarding MCO coverage or procedures, and updated information regarding Providers, languages spoken, and open and closed panels of Providers. Information that oral interpretation is available for any language and written information will be available in prevalent non-English languages. Information about how to access mental health, chemical dependency, Elderly Waiver, Home Care, dental, and Medical Emergency and Urgent Care services. A description of the MCO’s MSC+ and MSHO Care Systems, Care Coordination systems, Case Management systems, and any other distinguishing information that will assist the Enrollee in making a decision to enroll in the MCO’s MSC+ and/or MSHO product. If the MCO limits access to Providers by use of a Care System model, the MCO must describe which Providers are available to Enrollees based on the Care System chosen. Information concerning the selection process, including a statement that the Enrollee must select an MCO in which their Primary Care Provider or specialist participates if they wish to continue to obtain services from him or her. Any restrictions on the Enrollee’s freedom of choice among Network Providers. Information regarding open access of Family Planning Services and services prescribed by Minnesota Statutes, §62Q.14, and the availability of transitional services. Any language required by the Minnesota Department of Health (MDH) in order to provide protection and additional information for consumers of health care. Currently this language includes the following: “Enrolling in this health plan does not guarantee you can see a particular Provider on this list. If you want to make sure, you should call that Provider to ask whether he or she is still part of this health plan. You should also ask if he or she is accepting new patients. This health plan may not cover all your health care costs. Read your contract, or ‘Evidence of Coverage,’ carefully to find out what is covered.” If MDH determines that new language needs to be included, the MCO will incorporate it into the next available printing of the PCNL. A misrepresentation of Providers on the MCO’s PCNLs or Provider Directory may be determined by the STATE to be an intentional misrepresentation in order to induce Beneficiaries to select the MCO. When the MCO is new to a Service Area, the MCO must supply the STATE, or in certain cases, the Local Agency, with a supply of the final, printed and approved PCNL pursuant to the STATE’s specifications, in quantities sufficient to meet the STATE’s need. If the MCO also provides its PCNL in alternative format pursuant to section 3.6.9, then the MCO must also supply all Local Agencies within its Service Area with such alternative format. This time period may be waived by the STATE for the initial enrollment of current MCO MSC+ Enrollees into the MCO’s MSHO product. The MCO must update the PCNL as necessary to maintain accuracy, particularly with regard to the list of Network Providers, but not less than twice per year. The PCNL and all revisions to the PCNL must be submitted to the STATE along with a cover letter detailing all changes in the PCNL. The PCNL must be approved in writing by the STATE pursuant to section 3.6.3(A)(1). Such approval by the STATE shall not be unreasonably withheld. The MCO shall distribute the PCNLs to the Local Agencies and the STATE in a timely manner. The STATE shall respond to inquiries by the Local Agencies in a timely manner and shall communicate any issues or problems regarding distribution of the PCNLs to the MCO.