Primary Care Physicians (PCPs Clause Samples

Primary Care Physicians (PCPs. Primary Care Physicians (PCPs) may be individuals or group practices/clinics [Primary Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general practice, and internal medicine. Acceptable PCCs include FQHCs, RHCs and the acceptable group practices/clinics specified by ODJFS. As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP. The capacity-by-site requirement must be met for all ODJFS-approved PCPs. ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated Appendix H Aged, Blind or Disabled (ABD) population Page 3 capacity for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1 FTE). ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician’s assistant that is used to provide clinical support for a PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. In these situations it will not be necessary for the MCP to submit these specialists to the PVS database as PCPs, however, they must be submitted to PVS as the appropriate required provider type. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. The PCP requirement is based on an MCP having sufficient PCP capacity to serve 40% of the eli...

Primary Care Physicians (PCPs. This provision applies to Providers who are PCPs. When a PCP has initiated medication management services for a Covered Person to treat a behavioral health disorder and it is subsequently determined by the PCP, Health Plan and/or Subcontractor that the Covered Person should be transferred to a Regional Behavioral Health Authority (RBHA) prescriber for evaluation and/or continued medication management services, the PCP shall cooperate with Health Plan and/or Subcontractor, as applicable, in coordinating the transfer of the Covered Person’s care to the RBHA. Provider agrees that, the Integrated RBHA--entity contracted with ADHS to provide, manage and coordinate all medically necessary behavioral healthcare services for Title XIX eligible adults and all medically necessary physical health services for individuals with serious mental illness--will provide the full continuum of care including all outpatient and inpatient medical and behavioral health care as well as supportive services, per Member’s eligibility and Covered Services.

Primary Care Physicians (PCPs. If designated as a PCP, Provider must be accessible to Covered Persons 24 hours per day, 7 days per week. Further, PCPs must provide preventative care: (a) to children under age 21 in accordance with AAP recommendations for CHIP Covered Services and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Covered Services; and (b) to adults in accordance with the U.S. Preventative Task Force requirements. PCPs must also assess the medical needs and behavioral health needs of Covered Persons for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Covered Persons’ care with specialty care providers after referral and serve as a Medical Home to Customers. For THSteps, PCPs must: 1. Either be enrolled as THSteps Providers or refer Members due for a THSteps check-up to a THSteps provider; 2. Refer Members for follow-up assessment or interventions clinically indicated as a result of the THSteps check-up, including the developmental and behavioral components of the screening; 3. Submit information from the THSteps forms and documents to the Health Passport.

Primary Care Physicians (PCPs. If designated as a PCP, Provider must be accessible to Covered Persons 24 hours per day, 7 days per week. Further, PCPs must provide preventative care: (a) to children under age 21 in accordance with AAP recommendations for CHIP Covered Services and the THSteps periodicity schedule published in the THSteps Manual for Medicaid Covered Services; and (b) to adults in accordance with the U.S. Preventative Task Force requirements. PCPs must also assess the medical needs and behavioral health needs of Covered Persons for referral to specialty care providers and provide referrals as needed. PCPs must coordinate Covered Persons’ care with specialty care providers after referral and serve as a Medical Home to Customers.

Primary Care Physicians (PCPs. This provision applies to Providers who are PCPs. When a PCP has initiated medication management services for a Covered Person to treat a behavioral health disorder and it is subsequently determined by the PCP or Health Plan and/or Subcontractor that the Covered Person should be transferred to a Regional Behavioral Health Authority (RBHA) prescriber for evaluation and/or continued medication management services, the PCP shall cooperate with Health Plan and/or Subcontractor in coordinating the transfer of the Covered Person’s care to the RBHA. Provider agrees that, the Integrated RBHA--entity contracted with ADHS to provide, manage and coordinate all medically necessary behavioral healthcare services for Title XIX eligible adults and all medically necessary physical health services for individuals with serious mental illness--will provide the full continuum of care including all outpatient and