Primary Care Providers (PCPs Sample Clauses

Primary Care Providers (PCPs. 4.8.2.1 The Contractor shall offer its Members freedom of choice in selecting a PCP. The Contractor shall have written PCP Selection Policies and Procedures describing how Members select their PCP. 4.8.2.2 The Contractor shall submit these PCP Selection Policies and Procedures policies to DCH for review and approval as updated. 4.8.2.3 PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract. 4.8.2.4 The Contractor may require that Members are assigned to the same PCP for a period of up to six (6) months. In the event the Contractor requires that Members are assigned to the same PCP for a period of six (6) months or less, the following exceptions shall be made: 4.8.2.4.1 Members shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection; 4.8.2.4.2 Members shall be allowed to change PCPs with cause at anytime. The following constitute cause for change: · The PCP no longer meets the geographic access standards as defined in Section 4.8.13; · The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and · The Member requests to be assigned to the same PCP as other family members. 4.8.2.4.3 Members shall be allowed to change PCPs every six (6) months. 4.8.2.5 The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned Member. In addition, the PCP is responsible for coordinating and/or initiating Referrals for specialty care (both in and out of network), maintaining continuity of each Member’s Health Care and maintaining the Member’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services. The Contractor shall require that PCPs fulfill these responsibilities for all Members. 4.8.2.6 The Contractor shall include in its network as PCPs the following: 4.8.2.6.1 Physicians who routinely provide Primary Care services in the areas of: · Family Practice; · General Practice; · Pediatrics; or · Internal Medicine. 4.8.2.6.2 Nurse Practitioners Certified (NP-C) specializing in: · Family Practice; or · Pediatrics. 4.8.2.7 NP-Cs in independent practice must also have a current collaborative agreement with a licensed physician who has hospital admitting privileges. 4.8.2.8 FQHCs and RHCs may be included as PCPs. The Contractor shall maintain an accurate list of all Providers rendering care at these facilities. 4.8.2.9 Primary Care Public Health De...
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Primary Care Providers (PCPs. Primary Care Provider (PCP) means an individual physician (M.D. or D.O.), certain physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group practice within an acceptable specialty, contracting with an MCP to provide services as specified in paragraph (B) of OAC rule 5101: 3-26-03. 1. The APN capacity can count up to 10% of the total requirement for the county. Acceptable specialty types for PCPs include family/general practice, internal medicine, pediatrics, and obstetrics/gynecology (OB/GYN). 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. Appendix H Covered Families and Children (CFC) population 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. In determining whether an MCP has sufficient PCP capacity for a region, ODJFS considers a provider who can serve as a PCP for 2000 Medicaid MCP members as one full-time equivalent (FTE). 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 capacity for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1 FTE). Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will recognize for a specific PCP. 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 recognizes that MCPs will need to utilize specialty providers to serve as PCPs for some special needs members. Also, in some situations (e.g., continuity of care) a PCP may only w...
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Primary Care Providers (PCPs. 2.11.2.1 With the exception of members dually eligible for Medicare and TennCare, the CONTRACTOR shall ensure that each member has an assigned PCP, as defined in Section 1, who is responsible for coordinating the covered services provided to the member. For CHOICES members, the CONTRACTOR shall develop and implement protocols that address, at a minimum, the roles and responsibilities of the PCP and care coordinator and collaboration between a member’s PCP and care coordinator. 2.11.2.2 The CONTRACTOR shall ensure that there are PCPs willing and able to provide the level of care and range of services necessary to meet the medical and behavioral health needs of its members, including those with chronic conditions. There shall be a sufficient number of PCPs who accept new TennCare members within the CONTRACTOR’s service area so that the CONTRACTOR meets the access standards provided in Attachment III. 2.11.2.3 To the extent feasible and appropriate, the CONTRACTOR shall offer each member (other than members who are dually eligible for Medicare and TennCare) the opportunity to select a PCP. 2.11.2.4 The CONTRACTOR may, at its discretion, allow vulnerable populations (for example, persons with multiple disabilities, acute, or chronic conditions, as determined by the CONTRACTOR) to select their attending specialists as their PCP so long as the specialist is willing to perform all responsibilities of a PCP as defined in Section 1. 2.11.2.5 If a member who is not dually eligible for Medicare and TennCare fails or refuses to select a PCP from those offered within thirty (30) calendar days of enrollment, the CONTRACTOR shall assign a PCP. The CONTRACTOR may assign a PCP in less than thirty (30) calendar days if the CONTRACTOR provides the enrollee an opportunity to change PCPs upon receipt of notice of PCP assignment. 2.11.2.6 The CONTRACTOR shall establish policies and procedures to enable members reasonable opportunities to change PCPs. Such policies and procedures may not specify a length of time greater than twelve (12) months between PCP changes under normal circumstances. If the ability to change PCPs is limited, the CONTRACTOR shall include provisions for more frequent PCP changes with good cause. The policies and procedures shall include a definition of good cause as well as the procedures to request a change. 2.11.2.7 If a member requests assignment to a PCP located outside the distance/time requirements in Attachment III and the CONTRACTOR has PCPs availab...
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Primary Care Providers (PCPs. If Provider is a PCP Provider, Provider will comply will with all PCP requirements set forth by the State, including but not limited to: I. The PCP shall ensure coordination and continuity of care with Providers, including all Behavioral Health and LTC Providers, according to United’s policy; and II. The PCP shall ensure that the Member receives appropriate prevention services based on the Member’s age group, gender, and risk factors. III. PCPs shall refer Members for behavioral services based on the following indicators: • Suicidal/homicidal ideation or behavior; • At-risk of hospitalization due to a behavioral health condition; • Children or adolescents at imminent risk of out-of-home placement in a psychiatric acute care hospital or residential treatment facility; • Trauma victims; • Serious threat of physical or sexual abuse or risk to life or health due to impaired mental status and judgment. or other intellectual and developmental disabilities; • Request by Member or representative for behavioral health services; • Clinical status that suggests the need for behavioral health services; • Identified psychosocial stressors and precipitants; • Treatment compliance complicated by behavioral characteristics; • Behavioral and psychiatric factors influencing medical condition; • Victims or perpetrators of abuse and/or neglect and Members suspected of being subject to abuse and/or neglect; • Non-medical management of substance abuse; • Follow-up to medical detoxification; • An initial PCP contact or routine physical examination indicates a substance abuse problem; • A prenatal visit indicates substance abuse problems; • Positive response to questions indicates substance abuse, observation of clinical indicators, or laboratory values that indicate substance abuse; • A pattern of inappropriate use of medical, surgical, trauma, or emergency room services that could be related to substance abuse or other behavioral health conditions; and/or • The persistence of serious functional impairment associated with a primary behavioral health disorder.
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Primary Care Providers (PCPs. 4.8.2.1 The Contractor shall offer its Members freedom of choice in selecting a PCP. The Contractor shall have written PCP Selection Policies and Procedures describing how Members select their PCP. 4.8.2.1.1 The Contractor shall offer its P4HB Participants in the IPC component of the Demonstration freedom of choice in selecting a PCP. The Contractor shall have written PCP selection policies and procedures describing how IPC P4HB Participants select their PCPs. 4.8.2.2 The Contractor shall submit these PCP Selection Policies and Procedures policies to DCH for review and approval as updated. 4.8.2.3 PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract. 4.8.2.4 The Contractor may require that Members and IPC P4HB Participants are assigned to the same PCP for a period of up to six (6) months. In the event the Contractor requires that Members and XXX X0XX Participants are assigned to the same PCP for a period of six (6) months or less, the following exceptions shall be made:
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Primary Care Providers (PCPs. A PCP must be a physician or network provider/ subcontractor who provides or arranges for the delivery of medical services, including case management, to assure that all services, which are found to be medically necessary are made available in a timely manner as outlined in §4 of this Contract. The PCP may practice in a solo or group setting or may practice in a clinic (i.e., Federally Qualified Health Center or Rural Health Center) or outpatient clinic. The Contractor shall agree to provide at least one (1) full time equivalent (FTE) PCP per two thousand five hundred (2,500) members (SCHIP Program members and existing commercial members). Each eligible member shall be given the opportunity to choose a specific PCP within the Contractor’s provider network who will be responsible for the provision of primary care services and the coordination of all other health care needs. The Contractor shall assign a PCP to a member if the member fails to select a new PCP within the established timeframe or after a change in PCP has occurred (i.e. - PCP no longer participating). The Contractor shall submit to SCDHHS a copy of the procedures to be used to contact members for initial member education for approval prior to contract execution. These procedures shall adhere to the enrollment process and procedures outlined in §6 and the post enrollment procedures required in §8 of this Contract. The PCP selected for the member should be a provider that is located geographically close to the member's home, and/or best meets the needs of the member. However, the Program member has the freedom to request a change of PCP within the time frames and guidelines established by the Contractor. The time frames and guidelines established by the Contractor must not conflict with the Federal rules and regulations governing time frames. The Contractor shall identify to SCDHHS or its designee monthly any PCP approved to provide services under this Contract who will not accept new patients. The PCP shall serve as the member's initial and most important point of interaction with the Contractor's provider network. The PCP responsibilities shall include, at a minimum: 4.9.3.1.1 Managing the medical and health care needs of members to assure that all medically necessary services are made available in a timely manner; 4.9.3.1.2 Providing the coordination necessary for the referral of patients to specialists; and 4.9.3.1.3 Maintaining a medical record of all services rendered by the PCP and other ...
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Primary Care Providers (PCPs. For Participant’s enrolled in gatekeeper products, PCP’s are intended to be the patient's first source of care. Primary care providers are required to comply with any applicable Utilization Management and Quality Improvement programs as outlines in Section 2.9. Some Participant benefit contracts require the PCP to facilitate medically necessary specialist referrals via an approved process.
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Primary Care Providers (PCPs 
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Related to Primary Care Providers (PCPs

  • Provider If the Provider is a State Agency, the Provider acknowledges that it is responsible for its own acts and deeds and the acts and deeds of its agents and employees. If the Provider is not a State agency, then the Provider agrees to indemnify and save harmless the State and its officers and employees from all claims and liability due to activities of itself, its agents, or employees, performed under this contract and which are caused by or result from error, omission, or negligent act of the Provider or of any person employed by the Provider. The Provider shall also indemnify and save harmless the State from any and all expense, including, but not limited to, attorney fees which may be incurred by the State in litigation or otherwise resisting said claim or liabilities which may be imposed on the State as a result of such activities by the Provider or its employees. The Provider further agrees to indemnify and save harmless the State from and against all claims, demands, and causes of action of every kind and character brought by any employee of the Provider against the State due to personal injuries and/or death to such employee resulting from any alleged negligent act by either commission or omission on the part of the Provider.

  • Outpatient Services Physicians, Urgent Care Centers and other Outpatient Providers located outside the BlueCard® service area will typically require You to pay in full at the time of service. You must submit a Claim to obtain reimbursement for Covered Services.

  • Subcontracting for Medicaid Services Notwithstanding any permitted subcontracting of services to be performed under this Agreement, Party shall remain responsible for ensuring that this Agreement is fully performed according to its terms, that subcontractor remains in compliance with the terms hereof, and that subcontractor complies with all state and federal laws and regulations relating to the Medicaid program in Vermont. Subcontracts, and any service provider agreements entered into by Party in connection with the performance of this Agreement, must clearly specify in writing the responsibilities of the subcontractor or other service provider and Party must retain the authority to revoke its subcontract or service provider agreement or to impose other sanctions if the performance of the subcontractor or service provider is inadequate or if its performance deviates from any requirement of this Agreement. Party shall make available on request all contracts, subcontracts and service provider agreements between the Party, subcontractors and other service providers to the Agency of Human Services and any of its departments as well as to the Center for Medicare and Medicaid Services.

  • Inpatient Services Hospital Rehabilitation Facility

  • SERVICE PROVIDER’S PERSONNEL 10.1 The Service Provider’s Personnel shall be regarded at all times as employees, agents or Subcontractors of the Service Provider and no relationship of employer and employee shall arise between Transnet and any Service Provider Personnel under any circumstances regardless of the degree of supervision that may be exercised over the Personnel by Transnet. 10.2 The Service Provider warrants that all its Personnel will be entitled to work in South Africa or any other country in which the Services are to be performed. 10.3 The Service Provider will ensure that its Personnel comply with all reasonable requirements made known to the Service Provider by Transnet concerning conduct at any Transnet premises or any other premises upon which the Services are to be performed [including but not limited to security regulations, policy standards and codes of practice and health and safety requirements]. The Service Provider will ensure that such Personnel at all times act in a lawful and proper manner in accordance with these requirements. 10.4 Transnet reserves the right to refuse to admit or to remove from any premises occupied by or on behalf of it, any Service Provider Personnel whose admission or presence would, in the reasonable opinion of Transnet, be undesirable or who represents a threat to confidentiality or security or whose presence would be in breach of any rules and regulations governing Transnet's Personnel, provided that Transnet notifies the Service Provider of any such refusal [with reasons why]. The reasonable exclusion of any such individual from such premises shall not relieve the Service Provider from the performance of its obligations under this Agreement. 10.5 The Service Provider agrees to use all reasonable endeavours to ensure the continuity of its Personnel assigned to perform the Services. If any re-assignment by the Service Provider of those Personnel is necessary, or if Transnet advises that any such Personnel assigned are in any respect unsatisfactory, including where any such Personnel are, or are expected to be or have been absent for any period, then the Service Provider will promptly supply a replacement of equivalent calibre and experience, and any such replacement shall be approved by Transnet prior to commencing provision of the Services, such approval not to be unreasonably withheld or delayed.

  • Hospice Care If you have a terminal illness and you agree with your physician not to continue with a curative treatment program, this plan covers hospice care services received in your home, in a skilled nursing facility, or in an inpatient facility.

  • Health Care Operations “Health Care Operations” shall have the same meaning as the term “health care operations” in 45 CFR §164.501.

  • Applicable for Home Care Nurses: A full-time nurse reporting back to work upon request after completing the daily client assignment and following completion of a seven and three-quarter (7.75) hour shift but before commencement of their next scheduled shift shall be paid at overtime rates of pay with a guaranteed minimum of three (3) hours at overtime rates. If the extra time worked under this subsection commences within less than three (3) hours before the start of a shift, the guaranteed minimum of overtime pay will not apply. In such cases, the nurse will be paid at overtime rates from the time the nurse starts to work to the beginning of their shift.

  • Provider Services Charges for the following Services when ordered by a Physician for the treatment of an Injury or Illness.

  • Skilled Care in a Nursing Facility This plan covers skilled nursing services in a skilled nursing facility if: • the services are prescribed by a physician: • your condition needs skilled nursing services, skilled rehabilitation services or skilled nursing observation; • the services are provided by or supervised by licensed technical or professional medical personnel; and • the services are not custodial care, respite care, day care, or for the purpose of assisting with activities of daily living.

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