QUEST Integration - Responsibilities of the Primary Care Provider (PCP)

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

PCPs are providers licensed in Hawaii as an M.D. or D.O. and are either a family practitioner, general practitioner, general internist, pediatrician, obstetrician/gynecologist or geriatrician. PCPs may also be an advanced practice registered nurse with prescriptive authority (APRN-Rx) who is a registered professional nurse authorized by the State to practice as a nurse practitioner in accordance with State law and Hawaii statute. A physician's assistant recognized by the State Board of Medical Examiners as a licensed physician assistant may also be a PCP.

For patients with chronic conditions, other specialties may be designated as the PCP on a case by case basis. If the member has a historical relationship with the specialist as his or her PCP, and if the specialist or other health care practitioner agrees to assume the responsibilities of a PCP, that provider can be designated as the member's PCP. A confirmation may be made in writing, electronically or verbally. The specialist's or other health care practitioner's performance as the member's PCP will be monitored by HMSA.

Groups and clinics may also be designated as PCPs as long as the clinic is appropriately staffed to carry out the PCP functions.

Following are the responsibilities PCPs are expected to meet. Complete details are contained in the attachment to your QUEST Integration Medical Services Agreement.

• Supervising, coordinating, and providing all primary care to each assigned member.
• Coordinating and initiating referrals to specialty care (both in-network and if necessary out-of-network)
• Maintaining continuity of each member's health care and maintaining the member's health record
• Maintain admitting privileges to a minimum of one general acute care hospital in HMSA's network and on the island of service.For the island of Hawaii this means that the provider shall have admitting privileges to one general acute care hospital in either East Hawaii or West Hawaii, depending on which is closer.
• Having a written agreement with at least one other provider with admitting privileges to an acute care hospital within HMSA's network if the PCP (or specialist acting as a PCP) does not have admitting privileges.

In addition, PCPs are also required to meet the following:

• Maintaining the member's medical record that includes documentation of all services provided by the PCP as well as any specialty services.
• Assume responsibility for timely provision and documentation of EPSDT services, including referrals
• Assume ongoing responsibility for a patient's health maintenance and disease prevention, including telephone contact for urgent and emergency care and direction of patient to appropriate providers for care as necessary
• Review medical records forwarded to you by specialists and discuss treatment options with them
• Register referrals with HMSA's QUEST Integration referral registry when required
• Identify potentially high-cost, high-utilization, complex, or special needs cases for referral to QUEST Integration care coordinators for assistance in coordinating community resources and cost-effective appropriate care for the patient, including patients with a specific disease who may benefit from structured, patient education and support
• Attend or have a representative attend HMSA-sponsored QUEST Integration informational sessions and participate in HMSA-sponsored professional advisory review and education groups specifically for PCPs
• Fulfill all PCP responsibilities for members who are transitioning to another PCP until the other PCP has accepted the member, except in situations where the PCP is terminated from the HMSA QUEST Integration Network or the Medicaid program.

Accessibility Standards

The following accessibility standards have been adopted by HMSA's Plan for QUEST Integration Member for both PCPs and specialists:

• Immediate care and without prior authorization for emergency medical services
• Appointments within 24 hours for urgent care and for PCP pediatric sick visits
• Appointments within 72 hours for PCP adult sick visits
• Appointments within 21 days for behavioral health (routine visits for adults and children
• Appointments within 21 days for PCP routine visits for adults and children
• Appointments within 4 weeks or within sufficient timeliness to meet medical necessity for visits with a specialist or for non-emergency hospital admissions.

Emergency care must be available 24 hours a day, seven days a week through the use of recorded messages, the Physician Exchange service or backup coverage. Backup coverage also should be arranged when a provider is not available during regular practice hours (e.g., out of town, vacation, etc.). A hospital emergency room is not acceptable backup coverage, and patients should not routinely be directed to a hospital emergency room for care that is not considered urgent/emergent.

Note: The backup provider need not be part of HMSA's provider network and may submit claims directly to HMSA's Plan for QUEST Integration Members. However the backup provider must understand and agree that any services provided to QUEST Integration patients will be paid in accordance with the HMSA Medical Service Agreement with the provider for whom backup coverage is being provided. Please inform HMSA's QUEST Integration Provider Service of backup coverage and the time period for which backup is being arranged.

Patient Capacity

PCPs may limit the number of QUEST Integration patients they manage by declaring a capacity limit at the time of application. HMSA's QUEST Integration plan may auto assign members who do not select a PCP during their enrollment period to individual PCPs with a patient ratio of less than or equal to 1 to 300. No auto assignments will be made for PCPs who exceed the ratio; however, members may select those PCPs. Updates to capacity limits may be made as follows:

• Increases may be made at any time by mutual agreement between the PCP and HMSA.
• Decreases may be made 45 days after the date of written notification to HMSA so that affected patients have time to select a new PCP. The PCP should continue to provide care until the end of the 45-day period, or the member is reassigned, whichever occurs first.

PCP Changes

A member has the freedom to change his/her PCP at any time to include during annual plan change. Changes will be effective at the start of the new benefit year. At other times a member may request a change in PCP to be effective as soon as the change can be completed.

Members are free to select a PCP from HMSA's network of participating PCPs. The PCP must be located on the patient's island of primary residence, which is where the family's Med-QUEST files are maintained. As needed or requested by the member, HMSA's QUEST Integration Member Service staff can assist in the selection process by providing a list of available PCPs and any other additional information about a potential PCP that may help a member make a selection.

If a member's PCP plans to terminate from participation in HMSA's network of providers, HMSA will notify the member within 15 calendar days of the notification of the intent to terminate, including information on the PCP selection process, as well as an offer of assistance if needed.

The member must call HMSA's Member Service to initiate a change. Except for PCP changes during the annual plan change period, changes are generally effective as soon as the PCP change can be completed. PCPs are also required to keep a record of a patient's PCP changes. HMSA creates a report of past network PCPs and sends it to each patient's current PCP to file in the patient's medical records.

Withdrawal of Care

PCPs experiencing difficulty with a patient who is habitually uncooperative, disruptive, and abusive or a danger to persons in the office are encouraged to contact HMSA's care coordinators to intervene with the patient. The care coordinator will try to resolve the situation between the PCP and the patient by counseling and educating the patient about his/her responsibilities as a QUEST Integration member. If the situation cannot be resolved, a PCP may submit a withdrawal of care letter to the member/patient. After the PCP submits the certified withdrawal of care letter to the member, the PCP will complete the Care Navigation Services Referral Form with all the applicable information (e.g., member’s information, withdrawal of care information, additional comments, etc.) PCP’s should fax the completed Care Navigation Services Referral Form along with a copy of the member’s withdrawal of care letter to HMSA’s Care Navigators at 808-944-5607. HMSA will transition the member to another PCP; however, the original PCP must continue to provide services to the member until the other PCP has accepted the member. HMSA will transition the member to another PCP; however, the original PCP must continue to provide services to the member until the other PCP has accepted the member

Changes in PCP, as well as health plan or provider, will be made immediately if the member's health or safety is in jeopardy. QUEST Integration (QI) Care Navigation Referral Form

Delivery of Services

Benefit limitations and decisions on adjustment requests and precertification requests do not change a provider's responsibility and obligation to patients regarding the delivery of what the provider believes to be necessary healthcare services. Actions taken by HMSA and its Pre-Authorization Unit relate solely to determinations of whether a service meets the criteria for payment under the QUEST Integration plan. HMSA's Plan for QUEST Integration Members does not control or direct whether or how providers render services. Providers are responsible for the clinical decisions regarding care and treatment of patients and for the quality of those services.

Revision History