Ch 10: Primary Care Providers & Other Providers

This Chapter Includes:

1. Provider Types That May Serve as PCPs 2. PCP Responsibilities 3. Assignment of the Primary Care Provider 4. Member Panel Capacity 5. Continuity of Care for Existing Relationships 6. Access Standards

7. Referrals

8. Standing Referrals 9. Member Self-Referrals

10.Referrals to Specialists 11. Specialist Responsibilities 12.Hospital Responsibilities

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The primary care provider (PCP) is the foundation of VHP’s service delivery model. While the PCP plays a vital role, all VHP’s network providers play critical roles to ensure that VHP’s members receive the care they need at the right time and at the right site of service. VHP is committed to working with its providers, community organizations, and other groups to provide quality access to care to all VHP members. Below are the provider responsibilities for all contracted providers.

Provider Types That May Serve as PCPs

The health care professionals allowed to serve as PCPs include the following specialties, but are not limited to: • Internal Medicine • Pediatrics • Obstetrics/Gynecology • Family and General Practice

The PCP may practice in a solo practice or group setting or at a Federally Qualified Health Center (FQHC), Rural Health Center (RHC), Indian Health Center (IHC) or an outpatient clinic.

PCP Responsibilities

VHP members select a PCP who is responsible for coordinating the delivery of all health care services to the member, including referrals to appropriate specialists. This is accomplished through access to care 24 hours a day, seven days a week. Each PCP is assigned to a network (e.g., multi-specialty group practice, independent practice association, VHP direct provider network, etc.). Based on the member’s selection of their PCP and the network affiliation of the PCP, referrals should be directed into the network associated with the PCP. The member’s network is considered “preferred” for the purposes of referrals for specialty, hospital, and ancillary services. VHP will approve referrals outside the member’s preferred network in select circumstances, including for example, the absence or unavailability of a specialist in the member’s primary network or if the member requires services offered by a tertiary or quaternary hospital.

PCPs are responsible for the following activities: 1. Ensuring or facilitating member access to the health care system, preventive care, and appropriate treatment interventions; 2. Providing quality primary physical and behavioral health care services including preventive medical services; 3. Conducting health risk assessments and all other required assessments 4. Initiating and coordinating referrals to specialists or other contracted providers as medically indicated; 5. Assuring that members are not discriminated against in the delivery of services based on

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race, ethnicity, national origin, spoken language, religion, sex, age, mental or physical disability or medical condition, sexual orientation, gender identify, claims experience, medical history, evidence of insurability, disability, genetic information, and/or source of payment. 6. Following up with a member after an acute hospitalization and/or emergency room visit; 7. Assuring that no unnecessary or duplicate physical or behavioral health care services are provided; 8. Establishing a good medical record system for tracking, recalling, and identifying any clinical problems unique to members; 9. Providing basic case management services in collaboration with VHP’s Case Management

Department including, at a minimum:

I. Assisting with the identification of members in need of case management services;

II. Communicating directly with the member, family and/or VHP Case Management staff; and

III. Participating in initial and ongoing training and education related to VHP’s case management and care coordination services;

See Chapter 18, “Case Management” for further information about the case management services available from VHP.

10. Identifying and following up with any member who has missed or cancelled his/her appointment; 11. Establishing and maintaining hospital admitting privileges at one of VHP’s network hospitals or ambulatory surgery centers sufficient to meet the needs of VHP members or, enter an arrangement for management of inpatient hospital admissions of members at one of VHP’s network hospitals; 12. Managing the physical and behavioral health care needs of members to assure that all medically necessary services are made available in a culturally responsive and timely manner while ensuring patient safety at all times, including members with disabilities and chronic conditions; 13. Maintaining a current and complete medical record for the members in a confidential manner, including documentation of all services and referrals provided to the members, including, but not limited to, services provided by the PCP, specialist, and providers of ancillary services; 14. Following established procedures for coordination of in-network and out-of-network services for members, including obtaining authorizations for VHP specified inpatient and outpatient services, except for emergency services up to the point of stabilization, as well as coordinating services the member is receiving from another provider during a transition of care; 15. Actively participating in and cooperating with VHP’s quality initiatives and utilization, quality, and case management programs; 16. Scheduling an initial Health Risk Assessment (HRA) for a new member within 120 calendar days

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of assignment by VHP; 17. Ensuring that referrals are pre-approved by VHP and directed to providers associated with the network chosen by the member and reflected on the member’s ID card. Exceptions may be made for extenuating circumstances including for example, when the member’s network does not have availability, or the services needed by the member; and 18. Ensuring that referrals for elective, acute care hospital services are pre-approved by VHP and are cognizant of the level of care required for treatment of the member’s condition or disease. For example, in urgent or emergent situations, Stanford Health Care and Lucille Packard Children’s

Hospital are contracted by VHP for tertiary and quaternary care only.

Assignment of the Primary Care Provider

PCPs must see members who select them or who are assigned to them by VHP. Not all members select a PCP when enrolled with VHP. As a result, VHP’s initial priority is to make certain every member has a PCP. VHP’s Member Services staff are trained on the PCP selection process and helping members to establish a relationship with a PCP. In the event a member does not select a PCP, VHP will assign the member to a PCP in its network based on, but not limited to, PCP’s acceptance of new members, geographic location, and language preference.

A. PCP Selection and Assignment

1. VHP members may select a PCP or be assigned a PCP effective the first day of the month following enrollment. If a member does not choose a PCP, VHP will assign the member to a PCP. 2. PCPs are responsible for rendering all standard primary care services to VHP members in accordance with the VHP or Department of Managed Health Care (DMHC) access to care guidelines.

B. PCP Member Assignment Responsibility

1. PCPs are responsible for verifying member eligibility and PCP assignment prior to rendering primary care services.

C. Changing Assigned PCP

1. If a member is not assigned to a PCP at the time service is requested and the member would like to switch to a different PCP, the member may request a PCP change to be effective on the first day of the following month by one of the following methods: i. Contact the VHP Member Services Department at 1.888.421.8444 to speak with a member service specialist who can assist with PCP selection. ii.Email VHP’s Member Services Department at Member.services@vhp.sccgov.org to request a PCP change.

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2. All changes will be effective the first day of the month following the date VHP received the request for a PCP change.

D. Unassigned PCP Claims Denials

1. If a PCP sees a VHP member who is not assigned to the PCP’s panel, the claim is subject to denial by VHP, and in such instances the PCP will not be eligible to bill the member for payment for the services rendered.

E. Redirection of Members for Primary Care Services

1. If a member attempts to see a PCP who is not assigned to the member, and the member is unwilling or refuses to request a change in PCP assignment, the PCP office has the right to decline to render services to the member and may redirect the member back to VHP for assistance or directly to the member’s assigned PCP.

Member Panel Capacity

PCPs reserve the right to state the number of members they are willing to accept into their panel. VHP will not guarantee the number of members the PCP will be assigned by VHP. The number of members a PCP or a specialist can serve shall not exceed the following ratios:

• Primary Care: 1:2,000 • Specialists: 1:1,200

If a PCP would like to change the number of VHP members assigned to their practice, the PCP must contact Provider Relations at 1.888.421.8444. The change to membership assignment will immediately take effect, if the current total number of members does not exceed the newly requested limit. If the new requested limit exceeds the current number of members, VHP requires a 30-calendar-day notification for membership notification and reassignment.

A provider may not refuse to treat a VHP member if the provider has not reached the requested panel size limit or the ratios set forth above, as applicable.

Continuity of Care for Existing Relationships

VHP recognizes the importance of the patient-PCP relationship and strives to maintain the established continuity of care for its members during the PCP assignment process. Some members may have an existing patient-PCP relationship prior to their enrollment with VHP. If the pre-existing relationship is with a PCP who is contracted by VHP, VHP makes every effort to assign the member to that PCP in VHP’s eligibility system and to generate and issue an ID card that reflects the assignment of the member to the existing PCP.

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If a member has been receiving services from a provider who is not contracted with VHP, and the member wishes to continue to receive services from the provider, the member may contact the Member Services Department to speak to a member services specialist at 1.888.421.8444 who can assist the member with requesting consideration for continuity of care. Refer to Chapter 17, “Utilization Management” for detailed information on continuity of care requests.

Access Standards

VHP follows the appointment accessibility requirements as determined by DMHC and applicable regulatory and accrediting agencies. Providers are encouraged to participate in VHP’s timely access and appointment accessibility and availability audits. VHP monitors compliance with the appointment accessibility standards on at least an annual basis and uses the results of appointment standards monitoring to achieve adequate appointment availability and reduce unnecessary emergency room utilization. All providers are required to adhere to VHP and DMHC’s timely access standards. VHP’s annual audit may result in the implementation of a corrective action plan (CAP) by the provider and may be considered in the recredentialing process for the specific provider under review. See Chapter 12, “Timely Access Requirements.”

Referrals

PCPs are encouraged to refer a member when medically necessary care is beyond the scope of what the PCP can provide. The PCP must obtain prior authorization from VHP for referrals to certain specialty providers as noted in Chapter 17, “Utilization Management.”

Note: PCPs are affiliated with their independent medical association (IPA)/medical group (MG) in VHP’s core operating system and referrals for services outside the member’s chosen network may require prior approval by VHP. If you are part of an IPA/MG, work with the IPA/MG to ensure compliance with the IPA/MG’s referral authorization process.

Standing Referrals

A member may request a standing referral to a participating specialist, ancillary provider, or specialty care center if a member requires ongoing specialist treatment, has a life-threatening condition or disease, or a degenerative and disabling condition or disease. This referral is available only if the condition or disease requires specialized medical care over a prolonged period. The specialist or ancillary provider must have the necessary medical expertise and be properly accredited or designated to provide the medically necessary care required for the treatment of the condition or disease. Standing referrals to non-VHP contracted specialists, ancillary providers or specialty centers will only be approved if the service is not otherwise available in the member’s chosen network and from VHP’s contracted specialist and ancillary preferred network.

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Examples of standing referrals include but are not limited to: • End Stage Renal Disease • Transplants • Oncology/Radiation/Chemotherapy • HIV/AIDS

Member Self-Referrals

VHP permits members to obtain certain services without a referral from the PCP. The following health care services do not require a referral provided through the member’s chosen network or VHP’s preferred, contracted provider network: • Obstetrics/gynecology services • HIV testing and counseling • Tuberculosis diagnosis and treatment • Selected routine outpatient diagnostic services (i.e., routine laboratory tests, ultrasounds, x-rays, fetal non-stress testing) assuming these routine services are performed as part of a VHP approved visit to a specialist or performed by the PCP • Immunizations • Certain preventive service • MDLive telehealth visits for urgent care and behavioral health services

Referrals to Specialists

The PCP is responsible for coordinating the health care services for VHP members. PCPs can refer a member to a specialist in the member’s chosen network when care is needed that is beyond the scope of the PCP’s training or practice parameters. PCPs may refer members to a provider not contracted by VHP, affiliated with the member’s chosen network, or contracted in VHP’s preferred provider network in the event the specialist needed for the member’s condition is not available. However, PCPs must obtain prior authorization from VHP for referrals to providers not contracted by VHP or not affiliated with the member’s chosen network. The specialist making the referral is responsible for informing the PCP of the member’s status and proposed interventions throughout the course of the specialist’s treatment.

Specialist Responsibilities

VHP encourages specialists to communicate with the member’s PCP if there is a need to make a referral to another specialist rather than making such a referral without the PCP’s involvement. This allows the PCP to be aware of the additional requested services and provides for better coordination of the member’s care. This also ensures that the specialist to whom the member was referred is a contracted provider

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within the VHP network. The specialist may order diagnostic tests without the PCP’s involvement by following VHP’s referral guidelines as set forth in Chapter 17: “Utilization Management.”

Emergency admissions require notification to VHP’s Utilization Management Department within 24 hours of admission. Elective admissions require prior authorization from the Utilization Management Department.

Specialists must: • Maintain communication and on-going contact with the PCP; • Obtain authorization from VHP’s Utilization Management Department, if needed, prior to rendering services; • Coordinate the member’s care with the PCP; • Provide the PCP with consult reports and other appropriate records within five business days of completing the services requested in the referral; • Be available for, or provide, on-call coverage through another source 24 hours a day, seven days a week for the management of the member’s care; • Maintain confidentiality of medical information; and • Actively participate in and cooperate with VHP’s quality initiatives and utilization guidelines and quality and case management programs.

VHP providers should refer to their participating provider agreement for complete information regarding the provider obligations and reimbursement or contact their assigned Provider Relations Specialist with any questions or concerns.

Hospital Responsibilities

VHP uses a network of hospitals to deliver inpatient and other hospital-based services to VHP members. All services must be provided in accordance with applicable state and federal laws and regulations.

Hospitals must: • Obtain authorization for inpatient and specified outpatient services as specified in Chapter 17, “Utilization Management” and listed in the member’s current Evidence of Coverage (EOC), which is located on VHP’s website. (www.valleyhealthplan.org), except for emergency stabilization services. • Notify VHP’s Utilization Management Department of an admission within 24 hours of admission. • Notify VHP’s Utilization Management Department of all specialty care nursery/newborn intensive care unit (NICU) admissions within 24 hours of admission.

VHP’s Utilization Management Department can be notified of an admission by faxing the Inpatient Face Sheet to 1.408.885.4875 or by calling 1.408.885.4647.

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CH 11: Locum Tenens

This Chapter Includes:

1. Who is a locum tenens provider? 2. Temporary Transfer of Responsibility 3. How to Submit Claims for Rendered Services

4. Covering Provider

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Alert

Alert draws attention to critical information that has changed this year.

Contact

Contact information on who to contact for assistance.

Book Table of Contents

Click the purple VHP circle logo, located at the bottom left corner, to return to the main TOC.

2021 / Provider Manual