Examples of Primary Care Provider (PCP) in a sentence
More Definitions of Primary Care Provider (PCP)Primary Care Provider (PCP) means a participating provider who has the responsibility for supervising, coordinating, and providing primary health care to enrollees, initiating referrals for specialist care, and maintaining the continuity of enrollee care. PCPs include, but are not limited to Pediatricians, Family Practitioners, General Practitioners, Internists, Physician Assistants (under the supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as designated by the Contractor. The definition of PCP is inclusive of primary care physician as it is used in 42 CFR 438. All Federal requirements applicable to primary care physicians will also be applicable to primary care providers as the term is used in this Contract. Utilization Management (Utilization Review) Method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care (prospective review) or after care has been provided (retrospective care). Preadmission certification (preadmission review) A review for medical necessity of inpatient care prior to the patients admission. A review that grants prior approval for reimbursement of a health care service A review for medical necessity of tests and procedures ordered during an inpatient hospitalization Involves arranging appropriate health care services for the discharged patient Utilization review organization (URO) An entity that establishes a utilization management program and performs external utilization review services Combines health care delivery with the financing of services provided. Was developed as a way to provide affordable, comprehensive, prepaid health care services to enrollees Originally focused on cost reductions by restricting healthcare access through utilization management and availability of limited benefits Prevents providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services Payments made directly or indirectly to healthcare providers to encourage them to reduce or limit services Requires a managed-care plans that contract with Medicare or Medicaid to disclose information about physician incentive plans Exclusive provider organization EPO A managed-care plan that provides benefits to subscribers who are required to receive services from network providers A physician or healthcare facility under contract to the managed-care plan Physician hospital organization PHO Owned by hospitals and physician groups that obtain managed-care plan contracts Physicians maintain their own practices and provide healthcare services to plan members Management service organization MSO Usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices Group practice without walls GPWW Establishes a contract that allows physicians to maintain their own offices and share services, e.g., appointment scheduling and billing Integrated provider organization IPO Manages the delivery of healthcare services offered by hospitals, physicians (who are employees of the IPO), and other healthcare organizations, e.g., an ambulatory surgery clinic and a nursing facility A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices; the foundation is assigned a provider number and manages the practice's business Preferred Provider Health Care Act of 1985 Eased restrictions on preferred provider organizations Allowed subscribers to seek health care from providers outside of the PPO Preferred Provider Organization PPO Managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee Amendment to the HMO Act of 1973 Allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed Healthcare Effectiveness Data and Information Set (HEDIS) •Is developed by the National Committee for Quality Assurance (NCQA) •Created standards to assess managed care systems in terms of memberships, utilization of services, quality, access, health plan management and activities, and financial indicators •Established as an office of HCFA (now called CMS) to facilitate innovation and competition among Medicare HMOs Managed Care Organization • Responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system Provider accepts pre-established payments for providing health care services to enrollees over a period of time, usually one year. Primary Care Provider- PCP Responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists Quality Assurance Program Includes activities that assess the quality of care provided in a health care setting Quality Improvement System for Managed Care (QISMC) Established by Medicare to ensure the accountability of managed care plans in terms of objective, measurable standards Contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control Point of service plan POS Under which Patients have freedom to use the Managed care panel or providers or to self-refer to out of network providers Health maintenance organization HMO Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis Integrated delivery system Organization of affiliated providers sites that offer joint health care services to subscribers Exclusive provider organization EPO Provides benefits to subscribers who are required to receive services from network providers The development of patient care plans for the coordination and provision of care for complicated cases Submits written confirmation, authorizing treatment, to the Provider A second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility to perform the surgery Reimburse providers for individual healthcare services rendered Healthcare is provided by an HMO owned center or clinic or by physicians who belong to a specially formed medical group that serves the HMO Health Maintenance Organization Assistance Act of 1973 - HMOs Authorized federal grants and loans to private organizations that wished to develop health maintenance organizations. Employee Retirement Income Security Act of 1974 - ERISA Mandated reporting and disclosure requirements for group life and health plans (including managed care plans), permitted large employers to self-insure employee health care benefits, and exempted large employers from taxes on health insurance premiums. Omnibus Budget Reconciliation Act of 1981 - OBRA Federal legislation that expanded the Medicare and Medicaid programs. Provided states with flexibility to establish HMOs for Medicare and Medicaid programs Increased managed care enrollment resulted Tax Equity and Fiscal Responsibility Act of 1982 - TEFRA Modified the HMO Act of 1973 Created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specific Medicare requirements to provide Medicare covered services under a risk contract Defined risk contract as an arrangement among providers to provide capitated (fixed, prepaid basis) health care services to Medicare beneficiaries Defined competitive medical plan (CMP) as an HMO that meets federal eligibility requirements for a Medicare risk contract but is not licensed as a federally qualified plan Consolidated Omnibus Budget Reconciliation Act of 1985 - COBRA Allows employees to continue healthcare coverage beyond the benefit termination date Health Insurance Portability and Accountability Act of 1996 - HIPAA Mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information Balanced Budget Act of 1997 - BBA • Addresses healthcare fraud and abuse issues, and provides for DHHS Office of the Inspector General investigative and audit services in healthcare fraud cases • Encouraged formation of Provider service networks and Provider service organizations • Mandated risk-based managed care organizations to submit encounter data related to inpatient hospital stays of members • Established the Medicare+Choice program • Requires organizations to implement a quality assessment and performance improvement (QAPI) program so that quality assurance activities are performed to improve the functioning of M+C organizations Medicare Prescription Drug, Improvement, and Modernization Act Renamed the Medicare+Choice program Medicare Advantage Established the Medicare prescription drug benefit - Medicare Part D Amended the IRS Code of 1986 Which is responsible for supervising and coordinating health care services for enrollees?Primary Care Provider means a person responsible for supervising, coordinating, and providing initial and Primary Care to patients; for initiating referrals; and, for maintaining the continuity of patient care. A Primary Care Provider may be a Primary Care Physician (PCP) or Non-Physician Medical Practitioner.
Who is responsible for the health of a group of enrollees?Primary Care Physician (PCP) A "generalist" physician who, under certain health care plans, is accountable for the total health services of enrollees.
Who coordinates and supervises care of the patient?First and foremost, each patient has a nurse assigned to him or her at all times - 24 hours a day, seven days a week. This "primary nurse" works closely with your doctor to oversee and coordinate your care. Even when your nurse is on break, there is a nurse assigned to be responsible for your safe care.
Who is responsible for managing and coordinating a subscriber's health care in an HMO?The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans. An HMO is a kind of health insurance that has a list of providers, such as doctors, medical groups, hospitals, and labs. You must get all of your health care from the providers on this list.
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Who is responsible for supervising and coordinating healthcare services for enrollees?
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