Selecting PCP/CM Clause Samples
The 'Selecting PCP/CM' clause establishes the process by which a Primary Care Provider (PCP) or Case Manager (CM) is chosen for a participant in a health plan or care program. Typically, this clause outlines whether the participant can select their own PCP or CM, or if one will be assigned by the plan administrator, and may specify any requirements or limitations on the selection, such as network participation or specialty. Its core practical function is to ensure that each participant has a designated point of contact for coordinating care, thereby promoting continuity, accountability, and effective management of health services.
Selecting PCP/CM. A. The OHCA shall offer all recipients the opportunity to choose an appropriate PCP/CM from a directory of available PCP/CMs. Families with more than one member will be allowed to choose a different PCP/CM for each family member. If the potential member does not voluntarily select a PCP/CM timely, the OHCA will assign the member to a Contractor based on time/distance standards.
B. The OHCA shall inform the Contractor of its new enrollees and any terminations to the existing roster prior to the first day of each month. The Contractor is responsible for determining a recipient’s eligibility by contacting OHCA’s Eligibility Verification System (EVS.)
C. The Contractor shall specify a capacity of Medicaid members it is willing to accept under this contract. The maximum capacity is two thousand five hundred (2,500) for a full-time SoonerCare Contractor.
D. The OHCA does not guarantee the Contractor an enrollment level nor will the OHCA pay for members who are not eligible or excluded from enrollment.
E. The Contractor has no proprietary interest in SoonerCare members assigned to its panel, assigned to another PCP/CM’s panel, or eligible for any Medicaid program.
F. The Contractor may request a change in its capacity by submitting a written request to the SoonerCare program of the OHCA. This request is subject to review according to program standards. In the event the Contractor requests a lower capacity, the OHCA may lower the capacity by disenrolling members to achieve that number or allowing the capacity to adjust as members change their PCP/CM or lose eligibility.
Selecting PCP/CM. A. The OHCA shall offer all recipients the opportunity to choose an appropriate PCP/CM from a directory of available PCP/CMs. Families with more than one member will be allowed to choose a different PCP/CM for each family member. If the potential member does not voluntarily select a PCP/CM timely, the OHCA will assign the member to a Contractor based on time/distance standards.
B. The OHCA shall inform the Contractor of his/her new enrollees and any terminations to the existing roster prior to the first day of each month.
C. The Contractor shall specify a capacity of Medicaid members he/she is willing to accept under this contract. The maximum capacity is one thousand two hundred fifty (1,250) for a full-time SoonerCare Contractor.
D. The OHCA does not guarantee the Contractor an enrollment level nor will the OHCA pay for members who are not eligible or excluded from enrollment.
E. The Contractor has no proprietary interest in SoonerCare members assigned to his/her panel, assigned to another PCP/CM’s panel, or eligible for any Medicaid program.
F. The Contractor may request a change in his/her capacity by submitting a written request to the SoonerCare program. This request is subject to review according to program standards. In the event the Contractor requests a lower capacity, the OHCA may lower the capacity by disenrolling members to achieve that number or allowing the capacity to adjust as members change their PCP/CM or lose eligibility.