HealthPlus of Michigan Commercial HMO and Medicare Advantage HMO members must choose a primary care physician (PCP). A primary care physician is defined as one of the following specialties:
- Family Practice (General Practitioner)
- Internal Medicine
It is the PCP’s role to coordinate all health care services and when medically necessary, refer HealthPlus members to participating HealthPlus specialists.
The PCP will:
- Accept members up to the contracted limit and render services to any member at the same level, scope, and quality of care provided to all other clients and not discriminate based upon frequency or extent of covered services needed, age, sex, health status, race, religion, national origin, marital status, height, weight, or disability.
- Be available and accessible for medically necessary emergencies, outpatient and inpatient services 24 hours-a-day, seven days a week, including a sufficient on-call support system .
- Understand the reimbursement methodology for rendered services are based upon the HealthPlus fee-for-service or Medicare fee schedule.
- Look to HealthPlus for compensation for services rendered to a member when such services are covered by HealthPlus’ subscriber contract.
- Agree not to bill, charge, collect a deposit from, seek compensation from, seek remuneration from, surcharge, or have any recourse against a member except to the extent that copays are specified in an HealthPlus subscriber contract, or as permitted under principles of coordination of benefits for covered benefits.
- Preserve and enhance the member’s dignity.
- Prescribe or direct patient education for members, including personal health measures and social service assistance, when deemed appropriate.
- Provide services in a manner that assures the continuity of care and commitment of each physician to full cooperation in a health record-keeping system through which all pertinent information relating to the health care of its members is accumulated and readily available to persons authorized to review these records.
- Use his or her best efforts to bill within 60 days, but in all events, to submit to HealthPlus all claims for covered services within one year of the date of service or hospital inpatient discharge.
- Participate in and fully cooperate with HealthPlus’ utilization review, peer review, and quality assurance programs, including by way of example, not by way of limitation, pre-admission certification, emergency admission certification, and extension of hospital stays.
- Not discharge a member, except in situations that meet criteria established by HealthPlus.
- Comply with HealthPlus’ system for referrals and consultations among physicians and affiliated hospitals to facilitate coordination of health services and ensure continuity of care for members, specifically by communicating pertinent medical history and procedural results to providers, to eliminate duplication of services and enhance quality of care.
- Engage the services of non-plan physicians through HealthPlus approved referrals only when medically necessary and in conformity with the quality assurance and cost effectiveness programs of HealthPlus.