Selecting a PCP Clause Samples
The 'Selecting a PCP' clause defines the process by which an individual chooses a Primary Care Provider (PCP) within a health plan or insurance arrangement. Typically, this clause outlines the criteria for eligible PCPs, the method for making a selection—such as through an online portal or by submitting a form—and any deadlines or restrictions, like network participation requirements. Its core function is to ensure that members have a designated healthcare professional responsible for coordinating their primary medical care, thereby streamlining access to services and clarifying responsibilities for both the patient and the insurer.
Selecting a PCP i. Types of PCPs include family, general, and internal medicine practitioners, OB/GYNs who may be selected as PCPs for women, and pediatricians who may be selected as PCPs for children.
ii. You must notify AvMed of your PCP selection. Members must also notify and receive approval from AvMed prior to changing PCPs. PCP changes will become effective on the first day of the month after AvMed is notified.
Selecting a PCP. At the time You enroll, You must choose a PCP. If any Member is a minor or otherwise incapable of selecting a PCP, the Subscriber should select a PCP on Member’s behalf. If Your Dependents enroll, You and Your Dependents must choose a PCP from HMO’s directory of Participating Providers in order to receive Covered Services. For the most current list of Participating Providers visit the website at ▇▇▇.▇▇▇▇▇▇.▇▇▇. You may also refer to Your Provider directory or call customer service at the toll-free telephone number on the back of Your identification card. You may also request a written copy of the Participating Provider directory, which is updated quarterly, by calling customer service. Each directory identifies those Providers who are accepting existing patients only. HMO may assign a PCP if one has not been selected. Until a PCP is selected or assigned, benefits will be limited to coverage for Emergency Care. In addition to a PCP, female members may also select a participating Obstetrician/Gynecologist (OB/GYN Care) for gynecological and obstetric conditions, including annual well-woman exam and maternity care, without first obtaining a referral from a PCP or calling HMO. Members who have been diagnosed with a chronic, disabling or Life-Threatening illness may request approval to choose a Participating Specialist as a PCP using the process described in Specialist as PCP. Your PCP coordinates Your medical care, as appropriate, either by providing treatment or by issuing Referrals to direct You to Participating Providers. Except for Emergency Care/medical emergencies or certain direct-access Specialist benefits described in this Certificate, only those services which are provided by or referred by Your PCP will be covered. It is Your responsibility to consult with the PCP in all matters regarding Your medical care. If Your PCP performs, suggests, or recommends a course of treatment for You that includes services that are not Covered Services, the entire cost of any such non-Covered Services will be Your responsibility. You may change Your PCP by calling the customer service toll-free telephone number listed on Your identification card to make the change or to request a change form or assistance in completing that form. The change will become effective on the first day of the month following HMO’s receipt and approval of the request. In the event of termination of a Participating Provider of any kind, HMO will use best efforts to provide reasonable advance n...
Selecting a PCP. Members must choose a PCP from the list of Participating PCPs named by ▇▇▇. WHP has the right to change its list of Participating PCPs at any time. WHP will choose a PCP for Members who do not make their own selection.