The network primary care provider (PCP) is responsible for the complete care of his or her members, whether providing directly or by referral to the appropriate provider of care within the network and as such, accepts all associated case management responsibilities.
1. The PCP is the coordinator of all care. Therefore, the PCP agrees to ensure continuity of care to Prestige
Health Choice members and arranges for the provision of services when the PCP’s office is not open.
Documentation of ER visits, hospital discharge summaries or operative reports are to be obtained by the PCP and maintained in the medical record.
2. The PCP or OB Provider is responsible for notifying the Prestige Utilization Management Department by fax at 800-338-4195 when they identify a pregnant member. The fax notification should include the member’s name, ID number, and due date. A sample form that can be faxed is included in the forms section of this manual.
3. All providers must provide 24 hour a day/7 days a week coverage, and regular hours of operation must be clearly defined and communicated to the members, including arranging for on-call and after-hours coverage. Such coverage must consist of an answering service, call forwarding, provider call coverage or other customary means approved by AHCA. The after hours coverage must be accessible using the medical office’s daytime telephone number and the call must be returned within thirty (30) minutes of the initial contact.
4. All financial arrangements must be made between the PCP and covering physician. The PCP is also responsible for notifying Prestige Heath Choice in writing (two weeks prior to his/her absence) of the duration of the absence and the physician who will be providing the coverage. The covering physician must be a network physician.
5. The provider agrees to practice in his/her profession ethically and legally, provide all services in a culturally
competent manner, accommodate those with disabilities and not discriminate against anyone based on his/her
health status.
6. All Florida Healthy Kids PCPs must be board-certified pediatricians or family practice physicians.
7. The PCP must conduct a health assessment of all new enrollees within 90 days of the effective date of enrollment.
The PCP is responsible for notifying Prestige if unable to contact the member to arrange the initial
assessment with 90 days.
8. When clinically indicated, the provider agrees to contact Prestige Health Choice members regarding appropriate follow-up of identified problems, abnormal laboratory, radiological or other diagnostic findings.
9. The PCP must establish office procedures to facilitate the follow-up of member referrals and consultations. The PCP is responsible for obtaining and maintaining in the medical record, the results or findings of consultant referrals. If findings were communicated through telephonic consultation, a summary of the findings and name of the specialist must be documented.
10. The provider agrees to submit an encounter for each visit where the provider sees the member or the member receives a HEDIS (Health Plan Employer Data and Information Set) service.
11. The provider must participate in any system established by Prestige Health Choice to facilitate the sharing of medical records (subject to applicable confidentiality requirements in accordance with 42 CFR, Part 431,
Subpart F, including a minor’s consultation, examination and drugs for STDs in accordance with Section 384.30 (2), F.S.).
12. The provider agrees that when the need arises to contact Prestige Health Choice regarding interpretive services via AT&T or other service for members who may require the service.
13. If a new provider is added to a group, Prestige Health Choice must approve and credential the provider before the provider may treat members. Notification of changes in the provider staff is the responsibility of the provider’s office and must be communicated to Prestige Health Choice in writing.
14. The provider agrees to maintain a ratio of members to full time equivalent (FTE) physicians as follows:
• One physician shall not exceed a comprehensive patient load of 1,500; each physician extender (ARNP or PA) may increase comprehensive patient load by 750 patients, not to exceed 3000 patients per physician.
The PCP must certify to Prestige Health Choice whether or not his or her active member load exceeds 3,000 during the application and re-credentialing process.
15. The provider agrees to participate and cooperate with Prestige Health Choice in quality management, utilization review, continuing education, peer review and other similar programs established by Prestige Health Choice
