Primary Care Practitioner

• Encounters
  • Accurate Submission of Encounter Data
• Transfer of Non-Compliant Members
• Transfer of Medical Records
• 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 not 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 may, upon sixty (60) 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.

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Encounters

Primary care practitioners are required to report to Gateway all services they provide for Gateway members by submitting complete and accurate claims. All Gateway providers are contractually required to submit encounters for all member visits and all diagnosis codes that the member may suffer from.

Accurate Submission of Encounter Data

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. 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 Medicine, 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. 

It is very important that all diagnosis codes that are applicable to the member be submitted on every claim, especially chronic conditions.  The expected rate of submission for encounters is 100%.  Gateway provides support and education to practices as indicated by their encounter submission rates.

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Transfer of Non-Compliant Members

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.

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 Enrollment Department at:

Gateway Health Plan^®
Attention: Medicare Enrollment Department
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2740.

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. 

Primary care practitioners are required to provide emergency care for any Gateway member dismissed from their practice until the member transfer has been completed.

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Transfer of Medical Records

Primary care practitioners are required to transfer member medical records or copies of records to newly designated primary care practitioners within seven (7) business days from receipt of the request from the member or the member's new primary care practitioner, without charging the member.

Primary care practitioners are required to transfer member medical record or copies of records to newly designated Managed Care Organizations within seven (7) business days from receipt of the request from the Centers for Medicare and Medicaid Services or its agent.

Appointment Standards

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

A member should be seen by a practitioner as expeditiously as the member's condition warrants, based on the severity of symptoms.  If a practitioner is unable to see the member within the appropriate timeframe, Gateway will facilitate an appointment with a participating or non-participating practitioner, if necessary.