Primary Care Provider (PCP) Changes Sample Clauses

Primary Care Provider (PCP) Changes. The Contractor shall have written policies and procedures for allowing Members to select or be assigned to a new PCP when such a change is mutually agreed to by the Contractor and Member, when a PCP is terminated from coverage, or when a PCP change is as part of the resolution to an Appeal. The Contractor shall allow Members to select another PCP within ten (10) days of the approved change or the Contractor shall assign a PCP to the Member if a selection is not made within the time frame. Pursuant to 42 CFR 438.52, for Members in a designated rural area in which only the Contractor provides services, the restrictions on changing PCPs cannot be more restrictive than for Member Disenrollment as outlined in Section 27.3 “
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Primary Care Provider (PCP) Changes. The Contractor shall have written policies and procedures for allowing Enrollees to select or be assigned to a new PCP when such a change is mutually agreed to by the Contractor and Enrollee, when a PCP is terminated from coverage, or when a PCP change is as part of the resolution to an Appeal. The Contractor shall allow Enrollees to select another PCP within ten (10) Days of the approved change or the Contractor shall assign a PCP to the Enrollee if a selection is not made within the time frame. Pursuant to 42 C.F.R. 438.52, for Enrollees in a designated rural area in which only the Contractor provides services, the restrictions on changing PCPs cannot be more restrictive than for Enrollee Disenrollment as outlined in Section 26.13 “Enrollee Request for Disenrollment.” An Enrollee shall have the right to change the PCP ninety (90) Days after the initial assignment and once a year regardless of reason, and at any time for any reason as approved by the Enrollee’s Contractor. The Enrollee may also change the PCP if there has been a temporary loss of eligibility and this loss caused the Enrollee to miss the annual opportunity, if Medicaid or Medicare imposes sanctions on the PCP, or if the Enrollee and/or the PCP are no longer located in the same Medicaid Region. The Enrollee shall also have the right to change the PCP at any time for cause. Good cause includes the Enrollee was denied access to needed medical services; the Enrollee received poor quality of care; and the Enrollee does not have access to providers qualified to treat his or her health care needs. If the Contractor approves the Enrollee’s request, the assignment will occur no later than the first day of the second month following the month of the request. PCPs shall have the right to request an Enrollee’s disenrollment from his/her practice and to be reassigned to a new PCP in the following circumstances: incompatibility of the PCP/patient relationship; Enrollee has not utilized a service within one (1) year of enrollment in the PCP’s practice and the PCP has documented unsuccessful contact attempts by mail and phone on at least six (6) separate occasions during the year; or inability to meet the medical needs of the Enrollee. PCPs shall not have the right to request an Enrollee’s disenrollment from their practice for the following: a change in the Enrollee’s health status or need for treatment; an Enrollee’s utilization of medical services; an Enrollee’s diminished mental capacity; or, disruptiv...
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Related to Primary Care Provider (PCP) Changes

  • Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers Quality healthcare begins with a partnership between you and your primary care provider (PCP). When you need care, call your PCP, who will help coordinate your care. Your healthcare coverage under this plan is provided or arranged through our network of PCPs, specialists, and other providers. You’re encouraged to: • become involved in your healthcare by asking providers about all treatment plans available and their costs; • take advantage of the preventive health services offered under this plan to help you stay healthy and find problems before they become serious. Each member is required to provide the name of his or her PCP. However, if the name of a PCP is not provided with the application, your enrollment will not be delayed and your coverage will not be cancelled. How to Find a PCP or Other Providers Finding a PCP in our network is easy. To select a provider, or to check that a provider is in our network, please use the “Find a Doctor” tool on our website or call Customer Service. Please note: We are not obligated to provide you with a provider. We are not liable for anything your provider does or does not do. We are not a healthcare provider and do not practice medicine, dentistry, furnish health care, or make medical judgments.

  • Provider Network The Panel of health service Providers with which the Contractor contracts for the provision of covered services to Members and Out-of-network Providers administering services to Members.

  • Provider Services The Contractor’s system shall collect, process, and maintain current and historical data on program providers. This information shall be accessible to all parts of the MCMIS for editing and reporting.

  • Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.

  • Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered

  • Emergency and urgently needed care outside the service area Professional services of a physician, emergency room treatment, and inpatient hospital services are covered at eighty percent (80%) of the first two thousand dollars ($2,000) of the charges incurred per insurance year, and one-hundred percent (100%) thereafter. The maximum eligible out-of-pocket expense per individual per year for this benefit is four hundred dollars ($400). This benefit is not available when the member’s condition permits him or her to receive care within the network of the plan in which the individual is enrolled.

  • AIN Selective Carrier Routing for Operator Services, Directory Assistance and Repair Centers 4.3.1 BellSouth will provide AIN Selective Carrier Routing at the request of <<customer_name>>. AIN Selective Carrier Routing will provide <<customer_name>> with the capability of routing operator calls, 0+ and 0- and 0+ NPA (LNPA) 555-1212 directory assistance, 1+411 directory assistance and 611 repair center calls to pre-selected destinations.

  • CHILD AND DEPENDENT ADULT/ELDER ABUSE REPORTING CONTRACTOR shall establish a procedure acceptable to ADMINISTRATOR to ensure that all employees, agents, subcontractors, and all other individuals performing services under this Agreement report child abuse or neglect to one of the agencies specified in Penal Code Section 11165.9 and dependent adult or elder abuse as defined in Section 15610.07 of the WIC to one of the agencies specified in WIC Section 15630. CONTRACTOR shall require such employees, agents, subcontractors, and all other individuals performing services under this Agreement to sign a statement acknowledging the child abuse reporting requirements set forth in Sections 11166 and 11166.05 of the Penal Code and the dependent adult and elder abuse reporting requirements, as set forth in Section 15630 of the WIC, and shall comply with the provisions of these code sections, as they now exist or as they may hereafter be amended.

  • Provider Selection To the extent applicable to Provider in performance of the Agreement, Provider shall comply with 42 CFR 438.214, as may be amended from time to time, which includes, but is not limited to the selection and retention of providers, credentialing and recredentialing requirements and nondiscrimination. If Subcontractor and/or Health Plan delegate credentialing to Provider, Subcontractor and/or Health Plan will provide monitoring and oversight and Provider shall ensure that all licensed medical professionals are credentialed in accordance with Health Plan’s and the State Contract’s credentialing requirements.

  • Restricted Use By Outsourcers / Facilities Management, Service Bureaus or Other Third Parties Outsourcers, facilities management or service bureaus retained by Licensee shall have the right to use the Product to maintain Licensee’s business operations, including data processing, for the time period that they are engaged in such activities, provided that: 1) Licensee gives notice to Contractor of such party, site of intended use of the Product, and means of access; and 2) such party has executed, or agrees to execute, the Product manufacturer’s standard nondisclosure or restricted use agreement which executed agreement shall be accepted by the Contractor (“Non-Disclosure Agreement”); and 3) if such party is engaged in the business of facility management, outsourcing, service bureau or other services, such third party will maintain a logical or physical partition within its computer system so as to restrict use and access to the program to that portion solely dedicated to beneficial use for Licensee. In no event shall Licensee assume any liability for third party’s compliance with the terms of the Non-Disclosure Agreement, nor shall the Non-Disclosure Agreement create or impose any liabilities on the State or Licensee. Any third party with whom a Licensee has a relationship for a state function or business operation, shall have the temporary right to use Product (e.g., JAVA Applets), provided that such use shall be limited to the time period during which the third party is using the Product for the function or business activity.

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