Primary Care Provider Assignment Clause Samples

Primary Care Provider Assignment. The PIHP must have a process in place to assure each child is assigned a Medicaid certified primary care provider (PCP) who is board eligible or board certified in general or subspecialty pediatrics or family practice or who has pediatric nurse practitioner status. The process shall include a defined method to notify the member of such an assignment. The PIHP may choose to allow members an initial choice of primary care provider assignment. a. HMO primary care provider assignment strategy The strategy the PIHP uses to assign members to a primary care provider must take into account the health care needs of the member. The PIHP must ensure members are assigned a primary care provider that provides culturally appropriate care. Specifically, the provider must be able to relate to the member and provide care with sensitivity, understanding, and respect for the member’s culture. As part of the primary care provider assignment strategy, the PIHP must include the following: i. A process for assigning all members to an appropriate primary care provider including a step in which members are given the opportunity to choose their PCP. PIHPs shall ensure care is coordinated between the primary care provider, primary care clinic and/or specialists, which includes the development of a patient-centered and comprehensive treatment plan. ii. Communication methods that notify members of their primary care provider, primary care clinic or specialist that ensure the member utilizes their primary care provider or clinic, and encourages members to keep their scheduled appointments. iii. DHS encourages the PIHP to evaluate the effectiveness of their primary care provider assignment strategy to ensure quality of care. b. Changing and lock-in PCP assignments The PIHP must permit members to change primary providers at least twice in any year, and to change primary care providers more often than that for just cause, just cause being defined as lack of access to quality, culturally appropriate, health care. Such just cause will be handled as a formal grievance. c. Data sharing with PCP The PIHP must provide information on members to their assigned primary care provider on a monthly basis. The information must include, but is not limited to, utilization data and prescription drug data such as from the pharmacy extract provided by the Department.