Primary Care Practitioner

• Encounters
  • Accurate Submission of Encounter Data
• Capitation
• Capitation Reports
• Vaccines For Children
• Processing PCP Change Requests
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• Coordination of Behavioral Health and Physical Health Services
• Appointment Standards

Each member in a family has the freedom to choose any participating primary care practitioner, and a member may change to another primary care practitioner should a satisfactory patient-practitioner relationship develop.  A primary care practitioner agrees to accept a minimum number of Gateway members, as specified by their practitioner agreement, to their patient panel at each authorized office location without regard to the health status or healthcare needs of such members and without regard to their status as a new or existing patient to that practice or location.  The primary care practitioner must maintain at least twenty (20) weekly appointment hours per marketed location.

The primary care practitioner may, upon ninety (90) days prior written notice to Gateway, state in writing that they do not wish to accept additional members.  The written request excludes members already assigned to the primary care practitioner's practice including applications in process.

Primary care practitioners are required to report to Gateway all services they provide for Gateway members by submitting complete and accurate claims.

Gateway notifies all primary care practitioners quarterly of members on their panel who have not had an encounter in the past 6 months or have not complied with the EPSDT screening periodicity schedule.  Primary care practitioners are directed to contact all members including new members regarding the importance of EPSDT screens and regular visits.  Primary care practitioners should also notify Gateway of members who are non-compliant.

Encounter data provides the basis for many key medical management and financial activities at Gateway: 

• Quality of care assessments and studies;

• Access and availability of service evaluation;

• Program identification and evaluation;

• Utilization pattern evaluation;

• Operational policy development and evaluation, and;

• Financial analysis and projection.

To effectively and efficiently manage member's health services, encounter submissions must be comprehensive and accurately coded.  All Gateway providers are contractually required to submit encounters for all member visits.  Underreporting of encounters can negatively impact all stakeholders.

For primary care practitioners, encounter data is essential as many of Gateway's quality indicators are based on this information.  In capitated reimbursement systems, providers may lose the incentive to submit encounter data because reimbursement is not linked to each individual encounter.  Gateway evaluates primary care practitioner encounter data in two ways.  The rate of submitted encounters per member for individual primary care practitioner practices is measured and compared to a peer average based on specialty (Family Practice, Pediatric, Internal Medicine).  Additionally, Gateway extracts dates of service during on-site medical record review and compares the visit dates to encounters submitted to the health plan.  This rate is also compared to peer averages. 

The expected rate of submission for encounters is 100%.  Gateway provides support and education to practices as indicated by their encounter submission rates.

Primary care practitioners receive a monthly capitation payment based on the age and gender of the members who select them as their practitioner.  After monitoring monthly enrollment and disenrollment from each practitioner's member panel, Gateway issues to the practitioner, on or about the fifteenth of each month, a capitation check and report regarding the amount of payment per member.

Capitated services include all examinations, administrative and most medical procedures performed in the primary care office.  (Please refer to Gateway Agreement for details)  In addition to the capitation, primary care practitioners are routinely reimbursed for inpatient care, attendance at delivery, and other services outside the monthly capitation payment on a fee for service basis.

Gateway makes every effort to avoid retroactive deductions from the capitation.  These deductions are generally restricted to three months and are the result of the member changing his/her selected primary care practitioner or a delay in the Department of Public Welfare's reporting to Gateway a member's loss in eligibility.

Sample reports utilized by the primary care practitioner can be found in the Forms and Reference Material Section of this Manual.

Gateway requires all primary care practitioners who provide immunizations to children between the ages of 0-18 to participate in the free Vaccines For Children (VFC) Program.  All primary care practitioners will be reimbursed for the administration of any vaccine covered under the VFC Program when a claim is received for the appropriate immunization code.  Any immunizations not covered under the VFC Program, but covered by Gateway, will be reimbursed fee-for-service.  Please reference the Primary Care Practitioner's Agreement for fee schedules or contact your Provider Relations Representative for additional information.

Addition of Newborns
When a member selects Gateway, the member's effective date is usually the first of or the 15^th of the month.  When the member is a newborn, the member may be added any time of the month.  Because information is reported to Gateway retroactively, newborns will show up as a retroactive addition to the primary care practitioner's monthly panel listing.  Newborns will be effective on their date of birth or the date the newborn was added to the member's grant.

Capitation payments for newborns are as follows:

Services rendered during the newborn hospital stay are paid on a fee-for-service basis.

Processing PCP Change Requests

When a member wishes to change his or her primary care practitioner, the change is processed under the following guidelines:

• When the request is received prior to the 25^th of the current month, the new effective date will be the first of the following month.  For example, if a member's request is received on October 7^th, the member will be effective November 1^st with the new primary care practitioner.

• When the request is received on or after the 25^th of the current month, the new effective date will be the first of the subsequent month.  For example, if a member's request is received on October 28^th, the member will be effective December 1^st with the new primary care practitioner.

• If the member requests to change his or her primary care practitioner immediately, an exception to the above guidelines can be made if the situation warrants.

Primary care practitioners agree (a) not to discriminate in the treatment of his/her patients, or in the quality of services delivered to Gateway members on the basis of race, sex, age, religion, place of residence, health status or source of payment; and (b) to observe, protect and promote the rights of members as patients.  Primary care practitioners shall not seek to transfer a member from his/her practice based on the member's health status.  However, a member whose behavior would preclude delivery of optimum medical care may be transferred from the practitioner's panel.  Gateway's goal is to accomplish the uninterrupted transfer of care for a member who cannot maintain an effective relationship with a given practitioner.

Additionally, in order to assist Gateway practitioners in the management of members who violate office policy in regard to scheduled appointments, Gateway has instituted the following Member No-Show Policy:

Gateway will recognize the individual practitioner's written office policy in regard to scheduled appointments.  Gateway practitioners are responsible for recording no-show appointments in the member's medical record.

When a transfer is being conducted due to member no-show, the practitioner's notification should indicate that the practitioner wants to transfer the member to another primary care practitioner's practice. 

Should an incidence of inappropriate behavior or member non-compliance with no-show policies occur, and transfer of the member is desired, the practitioner must send a letter requesting that the member be removed from his/her panel including the member's name and Gateway ID Number, and, when applicable, state their no-show policy, and the member(s) who has (have) violated the policy to the Provider Relations Department at:

Gateway Health Plan
Attention: Provider Relations
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2740.

All written requests are forwarded to the Enrollment Department within 48 hours of the receipt of the practitioner's request.  The Enrollment Department notifies the original practitioner in writing when the transfer has been accomplished.  If the member requests not to be transferred, the primary care practitioner will have the final determination regarding continuation of primary care services. 

When the request is received prior to the 25^th of the month, the new effective date will be the first of the following month.  When the request is received on or after the 25^th of the current month, the new effective date will be the first of the subsequent month.  An exception to the above guidelines can be made if the situation warrants an immediate transfer.

The primary care practitioner shall transfer the member's medical records or copies of records to a newly designated primary care practitioner within seven (7) business days from receipt of the request from the Department of Public Welfare, its agent, the member or the member's new primary care practitioner, without charging the member.

The primary care practitioner shall transfer the member's medical record or copies of records to a newly designated Managed Care Organization within seven (7) business days from receipt of the request from the Department of Public Welfare or its agent.

No mental health or drug and alcohol services are covered by Gateway except for emergency room services, home health care, pharmacy services, and emergency transportation services.  Gateway is responsible for all emergency and non-emergency transportation in an ambulance to an emergency room and to a behavioral health facility.  All prescribed medications are dispensed through the Gateway pharmacy network.  This includes drugs prescribed by both physical health and behavioral health practitioners.  The only exception is that the Behavioral Health Managed Care Organization (BH-MCO) is responsible for the payment of Methadone and LAAM when used in the treatment of a substance abuse disorder, and when prescribed and dispensed by BH-MCO service practitioners.

Emergency services provided in general hospital emergency rooms are the responsibility of Gateway regardless of the diagnosis or services provided.  The only exception is for emergency room evaluations for voluntary or involuntary commitments pursuant to the 1976 Mental Health Procedures Act (50 P.S. Section 7101, et seq), which are the responsibility of the BH-MCO.

Both primary care practitioners and behavioral health clinicians have the obligation to coordinate care of mutual patients in accordance with state and federal confidentiality laws and regulations.  This includes but is not limited to: obtaining appropriate releases to share clinical information; making referrals for social, vocational, education or human services when a need is identified through assessment; notifying each other of prescribed medications; and being available for consultation when necessary.

Referrals are not necessary for members to receive the services of a behavioral health practitioner.

If a member requires home health care ordered by a BH-MCO practitioner that meets the conditions of 55 Pa. Code, Chapter 1249 (relating to Home Health Care Services), Section 1249.52 (relating to payment conditions for various services), the services would be covered by Gateway.

Please refer to the Quick Reference Section of this Manual for a listing of Behavioral Health Managed Care Organizations or behavioral health agencies and their corresponding telephone number, county serviced, and services provided.

Appointment Standards

Primary care practitioners agree to meet Gateway’s appointment standards, as follows: