Common use of Physicians or Designated Medical Group or IPA Clause in Contracts

Physicians or Designated Medical Group or IPA. The child must be enrolled with Blue Shield to continue coverage beyond the first 31 days from the date of birth or placement for adoption. See the Eligibility and Enrollment section for additional information. Primary Care Physician Relationship The Physician-patient relationship is an important element of an HMO Plan. The Member’s Primary Care Physician will make every effort to ensure that all Medically Necessary and appropriate pro- fessional services are provided in a manner com- patible with the Member’s wishes. If the Member and Primary Care Physician fail to establish a sat- isfactory relationship or disagree on a recom- mended course of treatment, the Member may con- tact Shield Concierge at the number provided on the back page of this EOC for assistance in select- ing a new Primary Care Physician. If a Member is not able to establish a satisfactory relationship with his or her Primary Care Physician, Blue Shield will provide access to other available Primary Care Physicians. Role of the Primary Care Physician The Primary Care Physician chosen by the Mem- ber at the time of enrollment will coordinate all Covered Services including primary care, preven- tive services, routine health problems, consulta- tions with Plan Specialists (except as provided un- der Obstetrical/Gynecological Physician services, Trio+ Specialist, and Mental Health and Substance Use Disorder Services), Hospice admission through a Participating Hospice Agency, Emer- gency Services, Urgent Services and Hospital ad- mission. The Primary Care Physician will also manage prior authorization when needed. Because Physicians and other Health Care Providers set aside time for scheduled appoint- ments, the Member should notify the provider’s office within 24 hours if unable to keep an appoint- ment. Some offices may charge a fee (not to ex- ceed the Member’s Copayment or Coinsurance) unless the missed appointment was due to an emer- gency situation or 24-hour advance notice is pro- vided. Obstetrical/Gynecological (OB/GYN) Physician Services A female Member may arrange for obstetrical and/or gynecological (OB/GYN) Covered Ser- vices by an obstetrician/gynecologist or family practice Physician who is not her designated Pri- xxxx Care Physician without a referral from the Primary Care Physician or Medical Group/IPA. However, the obstetrician/gynecologist or family practice Physician must be in the same Medical Group/IPA as the Member’s Primary Care Physi- cian. Obstetrical and gynecological services are defined as Physician services related to: