Common use of The Primary Care Physician Clause in Contracts

The Primary Care Physician. The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to a Participating Provider. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. A Member may receive a standing Referral from their PCP to a Participating Specialist if the Member has a chronic, disabling or life-threatening condition that requires specialized medical care over a prolonged period of time, and after consulting with their PCP, they select a Participating Specialist who is responsible for and capable of providing and coordinating their primary and specialty care. During the treatment period authorized by the Referral, such Participating Specialist shall be permitted to treat the Member without a further Referral from the Member’s PCP and to authorize such Referrals, procedures, tests and other medical services related to the Member’s condition as the Member’s PCP would otherwise be permitted to provide or authorize under this Certificate. The standing Referral shall be made in accordance with a written plan for Covered Benefits developed by the PCP, Participating Specialist, and Member. In certain other situations where a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. Please refer to the Covered Benefits section of this Certificate for details. Except for a Medical Emergency, Urgent Care service or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member’s PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member’s responsibility to consult with the PCP in all matters regarding the Member’s medical care. Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the group does not include a Provider qualified to meet the Member’s medical needs, the Member may request to have services provided by nonaffiliated Providers. If the Member’s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member’s responsibility.

The Primary Care Physician. The PCP coordinates a Member's medical care, as appropriate, either by providing treatment or by issuing Referrals to direct the Member to a another Participating Provider. The PCP can also order lab tests and x-rays, prescribe medicines or therapies, and arrange hospitalization. A Member may receive a standing Referral from their PCP to a Participating Specialist if the Member has a chronic, disabling or life-threatening condition that requires specialized medical care over a prolonged period of time, and after consulting with their PCP, they select a Participating Specialist who is responsible for and capable of providing and coordinating their primary and specialty care. During the treatment period authorized by the Referral, such Participating Specialist shall be permitted to treat the Member without a further Referral from the Member’s PCP and to authorize such Referrals, procedures, tests and other medical services related to the Member’s condition as the Member’s PCP would otherwise be permitted to provide or authorize under this Certificate. The standing Referral shall be made Except in accordance with a written plan for Covered Benefits developed by the PCP, Participating Specialist, and Member. In certain other situations where a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. Please refer to the Covered Benefits section of this Certificate for details. Except for a Medical Emergency, Urgent Care service Emergency or for certain direct access Specialist benefits as described in this Certificate, only those services which are provided by or referred by a Member’s PCP will be covered. Covered Benefits are described in the Covered Benefits section of this Certificate. It is a Member’s responsibility to consult with the PCP in all matters regarding the Member’s medical care. A female Member does not need a referral from her PCP for any medical service that is rendered by her Participating Women’s Principal Health Care Provider and provided as a Covered Benefit under the terms of the Certificate. Participating Women’s Principal Health Care Providers may also refer a female Member directly to other Participating Providers for Covered Benefits without the Member’s having to go back to her PCP. All HMO pre-authorization and coordination requirements apply. Certain PCP offices are affiliated with integrated delivery systems or other provider groups (i.e., Independent Practice Associations and Physician-Hospital Organizations), and Members who select these PCPs will generally be referred to Specialists and Hospitals within that system or group. However, if the group does not include a Provider qualified to meet the Member’s medical needs, the Member may request to have services provided by nonaffiliated Providers. In certain situations where a Member requires ongoing care from a Specialist, the Member may receive a standing Referral to such Specialist. Please refer to the Covered Benefits section of this Certificate for details. If the Member’s PCP performs, suggests, or recommends a Member for a course of treatment that includes services that are not Covered Benefits, the entire cost of any such non-covered services will be the Member’s responsibility.