Pennsylvania Code
Title 28 - HEALTH AND SAFETY
Part I - General Health
Chapter 9 - MANAGED CARE ORGANIZATIONS
Subchapter H - AVAILABILITY AND ACCESS
Section 9.678 - PCPs

Universal Citation: 28 PA Code ยง 9.678

Current through Register Vol. 54, No. 44, November 2, 2024

(a) A plan shall make available to each enrollee a PCP to supervise and coordinate the health care of the enrollee.

(b) A PCP shall meet the following minimum standards, unless a specialty health care provider is approved by the plan to serve as a designated PCP as provided for in § 9.683 (relating to standing referrals or specialists as pimary care providers):

(1) Provide office hours accessible to enrollees of a minimum of 20 hours-per-week.

(2) Be available directly or through on-call arrangements with other qualified plan participating PCPs, 24 hours-per-day, 7 days-per-week for urgent and emergency care and to provide triage and appropriate treatment or referrals for treatment. A participating provider may arrange for on-call services with a nonparticipating provider if the plan approves the arrangement, agrees to provide the level-of-benefit for the service provided by the nonparticipating provider, and agrees to hold the enrollee harmless for any errors committed by the nonparticipating provider that would result in noncoverage of covered benefits or would mislead the enrollee into believing a noncovered service would be covered.

(3) Maintain medical records in accordance with plan standards and accepted medical practice.

(4) Maintain hospital privileges or an alternate arrangement for admitting an enrollee, approved by the plan, that provides for timeliness of information and communication to facilitate the admission, treatment, discharge and follow-up care necessary to ensure continuity of services and care to the enrollee.

(5) Possess an unrestricted license to practice in this Commonwealth.

(c) A plan may consider a physician in a nonprimary care specialty as a primary care provider if the physician meets the plan's credentialing criteria and has been found by the plan's quality assurance committee to demonstrate, through training, education and experience, equivalent expertise in primary care. The plan shall comply with § 9.683.

(d) A plan may consider a certified registered nurse practitioner (CRNP), practicing in an advanced practice category generally accepted as a primary care area, as a PCP, if the CRNP meets the plan's credentialing criteria and practices in accordance with the Medical Practice Act (63 P. S. §§ 422.1-422.45) and its applicable regulations, 49 Pa. Code Chapter 18, Subschapter C (relating to certified registered nurse practitioners), and the Nurse Practice Act (63 P. S. §§ 211-225) and its applicable regulations, 49 Pa. Code Chapter 21, Subchapter C (relating to certified registered nurse practitioners).

(e) A plan shall include in its provider directory a clear and adequate notice of the possibility that the choice of a given provider as a PCP may result in access to a limited subnetwork based on the PCP's employment or other affiliation arrangements.

(f) A plan shall establish and maintain a policy and procedure to permit an enrollee to change a designated PCP with appropriate advance notice to the plan.

Disclaimer: These regulations may not be the most recent version. Pennsylvania may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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