BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire May 2012
SECTION 14 – BADGERCARE PLUS PRACTICE GROUP INITIATIVE (AS APPLICABLE)
The creation of the BadgerCare Plus Practice Group Initiative (PGI) is recognition that much of medicine is
practiced in administrative structures of medical practice groups. These structures provide opportunities to
decrease the administrative burdens of the referral and authorization process on our members, Primary Care
Providers (PCP) 6 , the Primary Care Clinic (PCC) 7 and the healthcare system as a whole. The PGI will allow (except
where noted below) for Group Health/Compcare BadgerCare Plus members to see any physician/provider of the
specific Practice Group (PG) 8 without obtaining a referral from the PCP or from GHC’s Health Management.
Optician services will not need a referral if provided by a Group Health/Compcare BadgerCare Plus contracted
provider.
Members are required to have behavioral health services coordinated by the contracted behavioral health provider
for their specific plan; in that regard the PGI involves all specialists except for Behavioral Health, Chemical
Dependency specialists, alternative medicine specialists such as massage therapists, acupuncturists, and/or
herbal therapists.
Not requiring referrals is not intended to diminish the role of the PCP or PCC. In fact, the role of the PCP will
increase in importance without the need for referrals as there will now be a greater need for communication
between the patient/member, the PCP, and the PGI specialist in order to obtain optimal health related success.
Group Health/Compcare BadgerCare Plus members will still need to select a Primary Care Clinic to coordinate
their care. GHC Health Management will continue to encourage members to work with their PCC and PCP to
obtain specialty care but we will not be imposing a requirement defining how a particular PG monitors the use of
specialty care within their specific group. We will continue to request that the member’s PCP be responsible for:
Coordinating all PG aspects of a member’s medical and healthcare needs;
Ensuring that the member receives clinically appropriate specialty medical services;
Responding to patient/member requests for specialty care and referring the patient/member to
specialists who are in the same PG as the PCP;
In situations where an appropriate specialist or service is not available in the PG, the PCP shall
request review and authorization for the member to see/receive out-of-Practice Group specialist
care or services to the GHC Health Management Department.
6
Primary Care Provider means a GHC /Compcare BadgerCare Plus provider who is a contracted physician to provide primary care services to members.
The contracted physician evaluates the member’s total health needs and provides personal medical care in one or more medical fields. When medically
needed he/she preserves continuity of care. He/she is also in charge of coordinating other provider health services and refers the member to other GHC
/Compcare BadgerCare Plus contracted providers as appropriate to the member. Primary care providers include the following: Family Practice, Internal
Medicine, Pediatric, and OB/GYN physicians in addition to Nurse Practitioners and Nurse Midwives.
7
Primary Care Clinic means a clinic contracted to provide primary care services to GHC /Compcare BadgerCare Plus members. The member must choose a
primary care clinic for their care. A member may change their primary care clinic up to two (2) times per year. Each family member may have a different
primary care clinic. A member may see any primary care provider in their primary care clinic.
8
Practice Group is an organized group of physicians that have joined together in a defined structure that facilitates care of the members between primary
care and specialty care.
[61]