Common use of Primary Care Providers (PCPs Clause in Contracts

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 Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions: · The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis. · Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness. 4.8.2.10 Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice. 4.8.2.11 The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider. 4.8.2.12 The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.

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 updatedwithin sixty (60) Calendar Days of Contract Award. 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: · : i. The PCP no longer meets the geographic access standards as defined in Section 4.8.13; · 4.8.12; ii. The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and · and iii. 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: · : i. Family Practice; · ; ii. General Practice; · ; iii. Pediatrics; or · or iv. Internal Medicine. 4.8.2.6.2 Nurse Practitioners Certified (NP-C) specializing in: · : i. 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 Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions: · The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis. · Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness. 4.8.2.10 Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice. 4.8.2.11 The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider. 4.8.2.12 The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.or

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 within sixty (60) Calendar Days of Contract Award and as updatedupdated thereafter. 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: · : 4.8.2.4.2.1 The PCP no longer meets the geographic access standards as defined in Section 4.8.13; · 4.8.14; 4.8.2.4.2.2 The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and · and 4.8.2.4.2.3 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: · : 4.8.2.6.1.1 Family Practice; · ; 4.8.2.6.1.2 General Practice; · ; 4.8.2.6.1.3 Pediatrics; or · or 4.8.2.6.1.4 Internal Medicine. 4.8.2.6.2 Nurse Practitioners Certified (NP-C) specializing in: · : 4.8.2.6.2.1 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 Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions: · The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis. · Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness. 4.8.2.10 Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice. 4.8.2.11 The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider. 4.8.2.12 The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.or

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: 4.8.2.4.1 Members and XXX X0XX Participants shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection; 4.8.2.4.2 Members and XXX X0XX Participants shall be allowed to change PCPs with cause at anytimeany time. The following constitute cause for change: · The PCP no longer meets the geographic access standards as defined in Section 4.8.134.8.14; · The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and · The Member or IPC Participant requests to be assigned to the same PCP as other family members. 4.8.2.4.3 Members and XXX X0XX Participants 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. 4.8.2.5.1 The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned IPC P4HB Participant. In addition, the PCP is responsible for coordinating and/or initiating Referrals for non-CMO paid or provided specialty care, maintaining continuity of each IPC P4HB Participant’s Health Care and maintaining the IPC P4HB Participant’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 IPC P4HB Participants. 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 Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions: · The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis. · Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness. 4.8.2.10 Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice. 4.8.2.11 The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider. 4.8.2.12 The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.

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: 4.8.2.4.1 Members and XXX X0XX Participants shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection; 4.8.2.4.2 Members and XXX X0XX Participants shall be allowed to change PCPs with cause at anytimeany time. The following constitute cause for change: · • The PCP no longer meets the geographic access standards as defined in Section 4.8.134.8.14; · • The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and · • The Member or IPC Participant requests to be assigned to the same PCP as other family members. 4.8.2.4.3 Members and XXX X0XX Participants 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. 4.8.2.5.1 The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned IPC P4HB Participant. In addition, the PCP is responsible for coordinating and/or initiating Referrals for non-CMO paid or provided specialty care, maintaining continuity of each IPC P4HB Participant’s Health Care and maintaining the IPC P4HB Participant’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 IPC P4HB Participants. 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 Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions: · • The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis. · • Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness. 4.8.2.10 Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice. 4.8.2.11 The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider. 4.8.2.12 The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.