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7.7.13 Provider Responsibilities
In addition to the requirements listed in "Provider Requirements and Information" , PCCM primary care providers have clearly defined roles, responsibilities, and contractual requirements.
Verifying Primary Care Provider Assignment
At the time that an appointment is made, the provider should ask the client for the name of their primary care provider. If the client has made a recent change of their primary care provider, direct the client to go to the provider listed on their primary care provider change notification letter.
Note: Providers may not request primary care provider changes for their clients. Federal guidelines prohibit influence by providers on a patient's choice of their primary care provider.
Primary Care Provider Services
PCCM defines the services to be provided and the responsibilities to be assumed by a PCCM primary care provider as follows:
• The primary care provider agrees to provide primary care services to PCCM clients. Primary care services are all medical services required by a client for the prevention, detection, treatment and cure of illness, trauma, or disease, which are covered and/or required services under Texas Medicaid. The primary care provider must ensure that clients 20 years of age or younger receive all services required by the THSteps program. All services must be provided in compliance with all generally accepted medical standards for the community in which services are rendered.
•Provide or arrange for medically necessary care within the following guidelines:
•Urgent Care. Within 24 hours after the request
•Routine Care. Within two weeks after the request
•Physical/Wellness Exams. Within four to eight weeks after the request
•Prenatal Care. Initial visit within 14 calendar days of the request or by the 12th week of gestation
•Refer clients to an approved Texas Medicaid provider or PCCM-contracted facility when the needed services are not available through the primary care provider's office or clinic. Specialists to whom primary care providers refer clients also should schedule appointments within the timeframes described above. Primary care providers may contact the PCCM Provider Helpline at 1-888-834-7226 for a list of contracted facilities.
•Coordinate, monitor, and document medical treatment and covered services delivered by all providers to each client, including treatment during inpatient stays.
•Comply with all authorization and notification requirements of PCCM.
•Verify the eligibility of each client prior to providing covered services to determine whether the client is eligible for services under PCCM on the date of service.
•Coordinate care for children receiving services from or who have been placed in the conservatorship of DFPS. Primary care providers are responsible for furnishing or arranging for all medically necessary services while the child is under the conservatorship of DFPS and until the child is placed in foster care and is no longer eligible for PCCM enrollment.
•Cooperate with and participate in PCCM utilization management (UM) programs.
•Maintain hospital admitting privileges at a PCCM-contracted facility as applicable or maintain a referral relationship with a provider with admitting privileges.
•Provide preventive services using clinically accepted guidelines and standards.
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