Coverage Arrangements

• Non-Participating Practitioner Coverage Arrangements
• Participating Practitioner Coverage Arrangements
• Claims for Coverage Services
• Specialty Care Practitioners

All participating practitioners must ensure 24-hour, 7 day-a-week coverage for members.  Coverage arrangements should be made with another Gateway participating practitioner.

When coverage arrangements are made with a non-participating practitioner, the participating practitioner must instruct the covering practitioner about Gateway's policies and procedures for referrals, use of emergency facilities, and hospital authorizations.  To request approval of a non-participating covering practitioner, the participating practitioner must submit a request to Gateway's Medical Director with a signed On-Call Practitioner Coverage Agreement, found in the Forms and Reference Materials Section of this Manual, from the practitioner that will be providing coverage for the practice.  All encounters must be billed under the name of the rendering practitioner, accompanied by a copy of the Coverage Agreement, and applicable referral for specialty care practitioners.  All services that are capitated for the member's assigned primary care practitioner will continue to be paid to the capitated primary care practitioner.  Any contractual Fee-For-Service charges will be paid directly to the non-participating covering primary care practitioner.  Participating practitioners will be held responsible for the actions of their non-participating coverage practitioners.

When a participating primary care practitioner has arranged, on a permanent basis, cross coverage arrangements for another participating primary care practitioner, the primary care practitioner should contact his Provider Relations Representative to set up a Provider Association between the two practitioners.  All encounters must be billed under the name of the rendering practitioner, not the member's assigned primary care practitioner.  All services that are capitated for the member's assigned primary care practitioner will remain capitated.  Any contractual Fee-For-Service charges will be paid directly to the participating covering primary care practitioner.

Covering practitioners, whether participating or not, must adhere to all of Gateway's administrative requirements.  Additionally, covering practitioners must agree not to bill the member for any covered services.  The covering practitioner should report all calls and services provided to the member's primary care practitioner.

Primary care practitioners agree that, in their absence, timely scheduling of appointments for members shall be maintained to meet at least twenty (20) appointment hours, per location, per week, which are sufficient and convenient to serve members.

Claims for Coverage Services

Payment for coverage services is the responsibility of the member's primary care practitioner.  Payment is not issued by Gateway to participating or non-participating covering practitioners for Primary Care Coverage Services unless the following services have been rendered:

For the above codes, practitioners may bill Gateway directly for reimbursement. 

Specialty Care Practitioners

Claimsfor services directly provided by an authorized specialist while covering for a Gateway specialist must be submitted on a CMS-1500 Form, clearly identified as a coverage service, and accompanied by a copy of the referral form.  Payment will be issued directly to the covering practitioner in accordance with Gateway's Fee Schedule.  Payment by Gateway is accepted as payment in full, and the practitioner may not balance bill the member.