Primary Care Physician (PCP) is a family practitioner, general practitioner, internist, or pediatrician who has been employed or contracted by Group to provide primary care services to Members and to be responsible for coordinating, referring, and managing the delivery of Covered Services to the Member. A PCP shall include an obstetrician-gynecologist who is qualified and has agreed with Group to serve as a PCP, and may also include other specialists if approved in writing by Blue Shield.
Primary Care Physician (PCP). A [Network] Provider who is a doctor specializing in family practice, general practice, internal medicine, [obstetrics/gynecology (for pre and post-natal care, birth and treatment of the diseases and hygiene of females,] or pediatrics who supervises, coordinates, arranges and provides initial care and basic medical services to a [Member]; [initiates a [Member]'s Referral for Specialist Services;] and is responsible for maintaining continuity of patient care. PRIVATE DUTY NURSING. Skilled Nursing Care for Members who require individualized continuous Skilled Nursing Care provided by a registered nurse or a licensed practical nurse.
Primary Care Physician (PCP). A [Network] Provider who is a doctor specializing in family practice, general practice, internal medicine, [obstetrics/gynecology (for pre and post-natal care, birth and treatment of the diseases and hygiene of females,] or pediatrics who supervises, coordinates, arranges and provides initial care and basic medical services to a [Member]; initiates a [Member]'s Referral for Specialist Services; and is responsible for maintaining continuity of patient care. PRIVATE DUTY NURSING. Skilled Nursing Care for Members who require individualized continuous Skilled Nursing Care provided by a registered nurse or a licensed practical nurse. PROVIDER. A recognized Facility or Practitioner of health care. PUBLIC HEALTH PLAN., With respect to a person who is a Federally Defined Eligible Individual, means any plan established or maintained by a State, the U.S. government, a foreign country, or any political subdivision of a State, the U.S. government, or a foreign country that provides health coverage to individuals who are enrolled in the plan. With respect to all other persons, Public Health Plan means any plan established or maintained by a State, the U.S. government, or any political subdivision of a State, or the U.S. government that provides health coverage to individuals who are enrolled in the plan. REASONABLE AND CUSTOMARY. An amount that is not more than the [lesser of: • the] usual or customary charge for the service or supply as determined by Us, based on a standard approved by the Board[; or [• the negotiated fee schedule.] The Board will decide a standard for what is Reasonable and Customary under this Contract. The chosen standard is an amount which is most often charged for a given service by a Provider within the same geographic area.
Primary Care Physician (PCP). A doctor of medicine legally authorized to practice medicine and surgery within the Commonwealth of Puerto Rico, who initially evaluates and provides treatment to beneficiaries. He/she is responsible for determining the services required by the beneficiaries, provides continuity of care, and refers the beneficiaries to specialized services if deemed medically necessary. Primary physicians will be considered those professionals accepted as such in the local and federal jurisdictions. The following are considered primary care physicians: Pediatricians, Obstetrician/Gynecologist, Family Physicians, Internists and General Practitioners. Each female beneficiary with a pregnancy factor has to select an obstetrician-gynecologist as her primary care physician. Once the pregnant woman completes her maternity care period, she will be allowed to continue with her primary care physician. PRIMARY MEDICAL GROUP: Profit or non-profit entity that groups or associates primary physicians. PRIMARY PROVIDERS: Shall consist of participating purveyors that are clinical laboratories, radiology facilities pharmacies and hospitals, without including emergency rooms. PROVIDER: An individual or entity that is authorized under the laws of the Commonwealth of Puerto Rico to provide health care services. QUALITY IMPROVEMENT (QI): The ongoing process of responding to data gathered through quality monitoring efforts, in such a way as to improve the quality of health care delivered to individuals. This process necessarily involves follow-up studies of the measures taken to effect change in order to demonstrate that the desired change has occurred. REFERRAL: Written authorization issued by the selected primary physician that allows the beneficiary to receive a service from another participating provider within a specific period of time.
Primary Care Physician (PCP). A doctor of medicine legally authorized to practice medicine and surgery within the Commonwealth of Puerto Rico, who initially evaluates and provides treatment to beneficiaries. He/she is responsible for determining the services required by the beneficiaries, provides continuity of care, and refers the beneficiaries to specialized services if deemed medically necessary. Primary physicians will be considered those professionals accepted as such in the local and federal jurisdictions. The following are considered primary care physicians: Pediatricians, Obstetrician/Gynecologist, Family Physicians, Internists and General Practitioners. Each female enrollee with a pregnancy factor has to select an obstetrician-gynecologist as her primary care physician. Once the pregnant woman completes her maternity care period, she will be allowed to continue with her primary care physician.
Primary Care Physician (PCP). A licensed family practice, general practice, pediatrics, non-specialized obstetricians and gynecologists, or internal medicine Physician who has entered into an agreement to coordinate the care of Members. A process used by Alliant to determine if a procedure or treatment is a medically necessary, covered service eligible under the plan for payment consideration. Prior Authorization approval is subject to all plan limits and exclusions. Any Physician, health care practitioner, pharmacy, supplier or facility, including, but not limited to, a Hospital, clinical laboratory, Ambulatory Surgery Center, Retail Health Clinic,Skilled Nursing Facility, Long Term Acute Care facility, or Home Health Care Agency holding all licenses required by law to provide health care services. A general hospital facility that provides Inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a Physician. Shall mean in Alliant’s discretion, services or supplies, whichare necessary for the care and treatment of illness or injury not caused by the treating Provider. Determination that a service(s) is reasonable will be made by Alliant, taking into consideration unusual circumstances or complications requiring additional time, skill and experience in connectionwith a particular service or supply; industry standards and practices as they relate to similar scenarios; and the cause of injury or illness necessitating the service(s). This determination will consider, but will not be limited to,the findings and assessments of the following entities: (a) The National Medical Associations, Societies, and organizations; and (b) The Food and Drug Administration. To be Reasonable, service(s) and/or fee(s) must follow generally accepted billing practices for unbundling or multiple procedures. Services, supplies, care and/or treatment that results from errors in medical care that areclearly identifiable, preventable, and serious in their consequence for patients, are not Reasonable. Alliant retains discretionary authority to determine whether service(s) and/or fee(s) are Reasonable based upon information presented to Alliant. A finding of Provider negligence and/or malpractice is not required for service(s)and/or fee(s) to be considered not Reasonable. Charge(s) and/or services are not considered to be Reasonable, and as such are not eligible for payment, whenthey result from Provider error(s) and/or facility-acquired condi...
Primary Care Physician (PCP). For HCSPs licensed by the DMHC for HMO products, a California licensed doctor of medicine or osteopathy who is a general practitioner, board-certified or eligible family practitioner, internist, obstetrician/gynecologist or pediatrician who has a contract with Contractor as a primary care physician and who has the primary responsibility for providing initial and primary Health Care Services to Enrollees, initiating referrals for specialist and hospital care, and maintaining the continuity of the Enrollee’s medical care.
