Specialists as PCPs. The Contractor shall offer pregnant Enrollees and Enrollees with Chronic Health Conditions, disabilities, or special health care needs the option of choosing a specialist to be their PCP or Medical Home. Such Enrollees or their Providers may request a specialist as a PCP at any time. The Contractor shall contact the Enrollee promptly after the request to determine whether the Enrollee needs a specialist as a PCP. The Contractor’s Medical Director will approve or deny requests after determining whether the Enrollee meets criteria and whether the specialist is willing to fulfill the role and all the obligations of PCP or Medical Home.
Specialists as PCPs. Members with disabling conditions, chronic conditions, or with special health care needs may request that their PCP be a specialist. The designation of a specialist as a PCP must be pursuant to a treatment plan approved by Contractor; in consultation with the PCP to which the Member is currently assigned, the Member and, as appropriate, the specialist. When possible, the specialist must be a provider participating in Contractor’s network. The specialist as a PCP must agree to provide or arrange for all primary care, including routine preventive care, and to provide those specialty medical services consistent with the Member’s disabling condition, chronic illness, or special health care need in accordance with Contractor’s standards and within the scope of the specialty training and clinical expertise. To accommodate the full spectrum of care, the specialist as a PCP must also have admitting privileges at a hospital in Contractor’s network.
Specialists as PCPs. The FIDA Plan must adopt and implement procedures by which a Participant with a life- threatening, degenerative, or disabling disease or condition can have a specialist serve as his/her PCP, if the specialist agrees to the requirements imposed on PCPs (IDT participation and otherwise). The designation of a specialist as PCP must be addressed in the Participant’s PCSP.
Specialists as PCPs. A Member may qualify to select a specialist to act as PCP if s/he has a disease or condition that is life threatening, degenerative, or disabling. The PH-MCO must adopt and maintain procedures by which an enrollee with a life-threatening, degenerative or disabling disease or condition shall, upon request, receive an evaluation and, if the Contractor's established standards are met, be permitted to receive: - A standing referral to a specialist with clinical expertise in treating the disease or condition; or - The designation of a specialist to provide and coordinate the enrollee's primary and specialty care. The referral to or designation of a specialist must be pursuant to a treatment plan approved by the Contractor, in consultation with the PCP, the enrollee and, as appropriate, the specialist. When possible, the specialist must be a health care Provider participating in the Contractor's Network. Information for MA Consumers must include a description of the procedures that a Member with a life-threatening, degenerative or disabling disease or condition shall follow and satisfy to be eligible for: - A standing referral to a specialist with clinical expertise in treating the disease or condition; or - The designation of a specialist to provide and coordinate the enrollee's primary and specialty care. It is the responsibility of the Contractor to ensure adequate Network capacity of qualified specialists as PCPs. These physicians may be predetermined and listed in the directory but may also be determined on an as needed basis. All determinations must comply with specifications set out by Act 68 regulations. The Contractor must establish and maintain its own credentialing and recredentialing policies and procedures to ensure compliance with these specifications. The Contractor must ensure that Providers credentialed as specialists and as PCPs agree to meet all of the Contractor's standards for credentialing PCPs and specialists, including compliance with record keeping standards, the Department's access and availability standards and other QM/UM Program standards. The specialist as a PCP must agree to provide or arrange for all primary care, consistent with Contractor preventive care guidelines, including routine preventive care, and to provide those specialty medical services consistent with the Member's "special need" in accordance with the Contractor's standards and within the scope of the specialty training and clinical expertise. In order to accommodate...
Specialists as PCPs. A Participant may select a specialist to act as PCP. The CHC-MCO must adopt and maintain procedures by which a Participant CHC: A standing referral to a specialist with clinical expertise in treating the disease or condition; or The designation of a specialist to provide and coordinate the Participant’s primary and specialty care. When possible, the specialist must be a healthcare Provider participating in the CHC-MCO’s Network. If the specialist is not a Network Provider, the CHC-MCO may require the specialist to meet the requirements of the CHC-MCO’s Network Providers, including the CHC-MCO’s credentialing criteria as developed in conjunction with the Department and QM/UM Program policies and procedures. Information for Participants must include a description of the procedures that a Participant shall follow to request and receive: A standing referral to a specialist with clinical expertise in treating the disease or condition; or The designation of a specialist to provide and coordinate the Participant’s primary and specialty care. The CHC-MCO must have adequate Network capacity of qualified specialists to act as PCPs. These physicians may be predetermined and listed in the directory but may also be determined on an as needed basis. The CHC-MCO must establish in conjunction with the Department and maintain its own credentialing and recredentialing policies and procedures to ensure compliance with these specifications. The CHC-MCO must require that Providers credentialed as specialists and as PCPs agree to meet all of the CHC-MCO's standards for credentialing PCPs and specialists, including compliance with record keeping standards, the Department's access and availability standards and other QM/UM Program standards. The specialist as a PCP must agree to provide or arrange for all primary care, consistent with CHC-MCO preventive care guidelines, including routine preventive care, and to provide those specialty medical services consistent with the Participant's assessed needs in accordance with the CHC-MCO's standards and within the scope of their specialty training and clinical expertise. In order to accommodate the full spectrum of care, the specialist as a PCP also must have admitting privileges at a hospital in the CHC-MCO’s Network.
