CurrentBaylor Scott & White Health PlanPolicy SWHP.QLI.005.P

Designation of Non-Primary Care Specialist as Primary Care Physician

Governs the process by which members (HMO and Medicaid lines of business) with complex or special healthcare needs may request designation of a non-primary care specialist to serve as their primary care physician (PCP); applies to all Scott & White Health Plan (SWHP) & ICSW members.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDesignation of Non-Primary Care Specialist as Primary Care Physician

Policy CodePolicy SWHP.QLI.005.P

Change TypeNo material change

Effective DateJul 11, 2017

Next Review Date

Key ActionSubmit completed application signed by member and non-primary care specialist to Medical Director for approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All SWHP & ICSWLines of business covered

HMO and MedicaidEligible member populations

RequiredApplication

Medical directorDecision authority

Designation Criteria and Process

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Designation criteria and process

Conditions and procedural requirements for approval:

ALL of the following

ANY of the following
- HMO members
- Medicaid members
ALL of the following
- Member has chronic complex conditions, special healthcare needs, disabling or life‑threatening conditions

ALL of the following

Specialist is willing to provide a Medical Home to the member (certified by specialist signature on application)
Specialist meets SWHP credentialing requirements
Specialist agrees to perform all required PCP duties
PCP duties to be performed are within the specialist's scope of license

ALL of the following

A completed SWHP application is submitted; the application includes description of the medical need and specialist demographic information
Application contains a signature certifying willingness to accept responsibility for coordination of all member health care needs (signed by the non‑primary care specialist)
Member signature is present on the application
After required signatures, the form is sent to the Medical Director at Scott & White Health Plan (1206 West Campus Drive, Temple, Texas 76502)

ALL of the following

Medical Director reviews the request and approves or denies the designation
If denied, the member has the right to appeal the decision with SWHP
Written notice of the decision is sent to the member, the non‑primary care specialist, and the member's PCP

ANY of the following

Medicaid members may utilize FQHCs, RHCs or similar community clinics as primary care providers
Medicaid members may utilize specialty physicians serving nursing facility residents as primary care providers

Request and Submission Process

Prior Authorization

Submit signed application to Medical Director; member may initiate request

Submit the completed application form signed by both the member and the non-primary care specialist to the Medical Director for approval. Medicaid members may initiate the request by calling RightCare Member Services; HMO members may call SWHP Customer Advocacy. After signatures are obtained, send the form to the Medical Director at Scott & White Health Plan, 1206 West Campus Drive, Temple, Texas 76502.

Application must include description of medical need, specialist demographics, and signatures of both specialist and member (specialist signature certifies willingness to coordinate all member care).
Medical Director will approve or deny the request; written notice is sent to the member, specialist, and PCP.
If denied, the member has the right to appeal.

Key Definitions

Non-Primary Care Physician Specialist

DefinitionPhysicians within specialties other than Family Medicine, Pediatrics, General Medicine, and Internal Medicine who do not meet the definition of primary care physicians.

Role implicationThese specialists are eligible to be considered for designation as PCP only if they meet SWHP credentialing and agree to perform PCP duties within their license scope (see procedure).

Related processDesignation requests require a completed application signed by both the specialist and the member and adjudication by the Medical Director.

Primary Care Physician (PCP)

DefinitionPhysician who practices in General Practice, Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology (OB/GYN), and APRNs and PAs when practicing under supervising physicians in qualifying specialties.

IncludesAdvanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs) when supervised by a qualifying PCP physician.

FunctionPCPs are responsible for providing the medical home and coordinating all member health care needs unless a non-primary care specialist is designated and approved.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDesignation of Non-Primary Care Specialist as Primary Care Physician

Policy CodePolicy SWHP.QLI.005.P

Change TypeNo material change

Effective DateJul 11, 2017

Next Review Date

Key ActionSubmit completed application signed by member and non-primary care specialist to Medical Director for approval.

SourceLink

On This Page

OpenPayer

Designation of Non-Primary Care Specialist as Primary Care Physician

Designation Criteria and Process

Coding and Credential Requirements

Request and Submission Process

Key Definitions