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Provider Manual

Role of the Affiliated Primary Care Provider

Last Updated on August 28, 2018

Upon enrollment, every member is encouraged to choose a Primary Care Provider (PCP). Participating PCPs may be from general practice, family practice, general internal medicine, obstetrics/gynecology (limited), adolescent medicine, and/or pediatrics.

Role

“Primary care provider” refers to a provider who supervises, coordinates, and provides initial and basic care to members; who may initiate referrals for specialty care; and who maintains continuity of patient care for members of the BadgerCare Plus Program. PCPs will continually deliver high quality care for members as cost-effectively as possible. PCPs will continue to educate themselves about managed care and the mechanisms that must be in place for it to operate successfully. PCPs will know the managed care system and support managed care principles.

Coverage

The PCP agrees to provide high quality, cost-effective medical care to BadgerCare Plus members 24 hours a day, 7 days a week, consistent with the generally recognized standards in the community. For cross-coverage, the PCP will arrange for members to be treated by other PCPs who are participating with BadgerCare Plus.

Referrals

If a member has an out-of-area emergency hospital admission, then the PCP will assist Security Health Plan with coordinating transfer of care to an affiliated hospital or physician/provider if appropriate. Security Health Plan will provide members with on-going education, encouragement, and direction to have their PCPs provide or coordinate all care required.

Hospitalization

If nonemergent hospital admission is required, the PCP will coordinate all in-patient hospital care.

Compliance

The PCP will permit Security Health Plan full access to members’ medical records and will allow the replication of such records. Original records shall not be removed from PCP premises. The PCP, upon request, agrees to promptly provide a full copy of all medical records upon the transfer of a member to another primary care site.

The PCP shall submit claims in accordance with Security Health Plan’s claim submission requirements.

The PCP will comply with Security Health Plan credentialing and recredentialing requirements and shall notify Security Health Plan immediately upon occurrence as to any change in such credentialing material.

The PCP agrees to cooperate with Security Health Plan’s Quality Improvement and Utilization Management Programs, including furnishing information and abiding by decisions made.

The PCP will permit the use of his/her name and professional designation on a list of participating providers. This list is maintained by Security Health Plan for purposes of informing prospective and existing members of participating providers available to be selected.

If a member fails to establish or maintain a satisfactory provider/patient relationship with the PCP, the PCP may contact Security Health Plan’s Customer Service Department for assistance. 

Role of the Affiliated Specialty Care Physician

Definition

A BadgerCare Plus “affiliated specialty care physician” is defined as a provider who has signed a contract with Security Health Plan to deliver medical services in his/her specialty to those members who are referred from the affiliated PCP.

Role

The role of the affiliated specialty care physician involves a direct relationship with the members’ PCP.

Reimbursement

Per contractual arrangement, Security Health Plan will reimburse the affiliated specialty care physician in accordance with Security Health Plan’s fee schedule for covered services.