Under certain circumstances, a specialist may be approved by Prestige Health Choice to serve as a member’s PCP when a member requires the regular care of the specialist. The criteria for a specialist to serve as a member’s PCP include the existence of a chronic, life-threatening illness or condition of such
complexity whereby:
• The need for multiple hospitalizations exists;
• The majority of care needs to be given by a specialist; and
• The administrative requirements arranging for care exceed the capacity of the PCP. For example, this would include members with complex neurological disabilities, chronic pulmonary disorders, HIV/AIDS, complex hematology/oncology conditions or cystic fibrosis.
• In the event the specialist becomes the primary care provider, they must adhere to primary care HEDIS requirements. The specialist must meet the requirements for PCP participation (including contractual obligations and credentialing), provide access to care 24 hours a day/7 days a week and coordinate the member’s healthcare including preventive care. When such a need is identified, the member or specialist
must contact Prestige Health Choice’s Care Management Department and complete a Specialist as PCP Request Form.
A Prestige Health Choice case manager will review the request and submit it to the Prestige Health Choice Chief Medical Officer. Prestige Health Choice will notify the member and the provider of its determination in writing within 30 days of receiving the request. Should Prestige Health Choice deny the request, Prestige Health Choice will provide written notification to the member and provider the reason(s) for the denial
of the request within one day. Specialists serving as PCPs will continue to be paid their contracted rate while serving as the member’s PCP. The designation cannot be retroactive. For further information, see the Specialist as PCP Request Form in the “Forms” section of the manual.
