Commercial - Physician Responsibilities |
Overview
As part of continuing quality improvement program and in accordance with
applicable NCQA guidelines, ConnectiCare will monitor provider performance
against the standards outlined in this section and in accordance with the
provider agreement.
ConnectiCare Requirements
Primary Care Physicians (PCPs):
- Act as a health care manager for members to arrange and coordinate their medical
care, including but not limited to, routine care, and follow-up care
after the receipt of emergency services
- Refer members for specialty services and log those referrals in the
telephonic Eligibility & Referral Line for members in the Personal Care Plan
or Point-of-Service Personal Care Plan
- Offer accessibility for appointments a minimum
of twenty (20) hours per week, excluding on-call hours. In addition, all
physician offices must have twenty-four (24) hour, on-call capability, either
directly or through an answering service, not an answering machine.
- Offer timely accessibility for appointments to members for:
- Preventive care visits within 60 days
- Routine primary care visits within 30 days
- Urgent care visits with 24 hours
- After-hours coverage
Specialists:
• Provide continuity and coordination of care by sending a written report
to PCPs regarding any treatment or consultation provided to members, whenever the member receives
services from a specialist provider, whether the service was a result of a PCP
referral or the member made his/her own arrangements
• OB/Gyn offices must have twenty-four (24) hour on-call
capability, either directly or through an answering service, not an answering
machine.
All Contracted Physicians:
• Review policy statements issued through the Physician & Provider
Manual or its updates via the Office Visit, our provider newsletter,
and adhere to the policies and administrative requirements of ConnectiCare.
• Refund overpayments made to you by ConnectiCare, as indicated in a
written notice from ConnectiCare. Such refunds must be made to ConnectiCare within thirty (30) days of receipt of the
written notice unless other arrangements are made in writing and accepted by
ConnectiCare.
• Arrange for the provision of medical services to ConnectiCare members by a
participating practitioner after hours, on weekends, vacations, and holidays. Services from non-participating
covering practitioners may not be covered, unless otherwise approved by
ConnectiCare.
• Help members obtain their benefit coverage by obtaining written pre-authorization
prior to referring for out-of-plan services, as appropriate.
• Provide covered benefits that are in accordance with community/national
standards of medical care and medical ethics.
• Facilitate candid discussion with members regarding appropriate or medically
necessary treatment options for their condition, regardless of cost or benefit coverage. Such
discussion should include complete current information concerning a diagnosis,
treatment, and prognosis, in terms that the member (or member’s designee) can be
expected to understand.
• Provide to members the information necessary to give informed consent prior to the start of
any procedure or treatment.
• Maintain appropriate liability insurance coverage, as stipulated in the applicable provider
agreement(s).
• Maintain appropriate medical records regarding members and their treatment, recognizing that said
records are confidential and ensuring that they are maintained in accordance
with legal and ethical requirements concerning confidentiality and security.
• Cooperate with ConnectiCare or its designee in the resolution of members' complaints, expedited appeals,
appeals and/or grievances.
• Comply with other administrative requirements as specified in the applicable contract or stipulated in
this Physician & Provider Manual or its updates.
• Promote the efficient delivery of medical services to maximize health care resources and the member’s premium
dollar and improve quality of care provided.
• Refrain from providing treatment to the physician's own family members.
NCQA Requirements
All Contracted Physicians:
• Comply with ConnectiCare medical records policy, quality assurance programs, medical
management programs, and HEDIS data collection.
• When making a referral (if required), transmit all necessary information to the
physician receiving the referral.
• When furnishing a service upon referral, report appropriate information back to the referring
practitioner.
State Requirements
Connecticut:
Massachusetts:
New York:
