As managers of members’ care, PCPs and PSPs have accepted the responsibility to provide a wide range of services, including, but not limited to:
Office and hospital care[1];
Routine exams;
Well adult, children, and infants care;
Immunizations and other preventive care;
Diagnosis and treatment of disease;
Counseling/education of members and their families regarding medical care and lifestyle choices;
Coordination of diagnostic evaluations, specialty consultations and treatments, hospital and home care services;
Initiation and coordination of case management activities on behalf of members; and
Participation in quality improvement initiatives.
Within the terms of their participation agreement, PCPs and PSPs agree to maintain the continuity of members’ healthcare and coordinate care provided outside of their scope of expertise through the various processes outlined in this chapter.
Non-primary care physicians may coordinate care for members with chronic, disabling or life-threatening illnesses.
Participating Specialty Care Physicians work in conjunction with the member’s chosen PCP to provide quality, cost-effective medical services. Specialists have agreed to communicate with the PCP on an ongoing basis for the benefit of the member. This open communication process helps to eliminate duplication of effort and promotes a collegial approach to member care. By working together, the PCP, the specialist, the member, and MHP have the greatest opportunity to maximize the benefits of education and alternative care management. While the communication process is important for members covered under all MHP programs, a written plan referral is not required for providers in the St. Louis metropolitan area.
MHP reserves the right to make changes in medical management requirements subject to appropriate notification to practitioners and other providers. The notification will be in the form of newsletters or other updates and should be considered addendums to this manual.
The following appointment access timelines should be adhered to by all participating providers, except certain ancillary service providers*:
|
Routine Care Without Symptoms |
30 calendar days |
|
Routine Care With Symptoms |
5 business days or one week |
|
Prenatal Care |
1st Trimester: 7 calendar days 2nd Trimester: 7 calendar days 3rd Trimester: 3 calendar days Emergency Obstetrical Care: 24 Hours per day, 7 days a week |
|
Urgent Care |
24 hours |
|
Emergent Medical Services |
Must be available immediately 24 hours a day, 7 days a week |
|
Hospital Facility |
24 hours, 7 days a week |
|
Behavioral Health Non-Emergent |
5 business days or one week |
|
Behavioral Health Urgent Care |
24 hours |
Participating providers, including mental health therapists, are available to assist/direct members’ medical/mental health needs 24-hours per day 7-days per week.
Participating providers or their designated coverage, including mental health therapists, are accessible via telephonic services. This information is provided to members to ensure timely access to the providers.
Preferable after-hours access mechanisms include answering machines or direct linkage to exchange services. Use of an after-hours answering machine is only considered an acceptable means of supporting 24-hour coverage when direction is provided to members regarding methods to access a provider’s after-hours pager, exchange, and/or covering provider.
*Providers exempt from these guidelines: Ambulatory Surgery Centers, Chiropractors, Dialysis Facilities, Durable Medical Equipment Providers, Freestanding Radiology, Hearing Aide Providers, Laboratory Draw Sites, Orthotic and Prosthetic Providers, Physical Therapy Providers, Sleep Labs, Urgent Care Facilities.