5 ROLES AND RESPONSIBILITIES
5.2 The PCP Role
Members are asked to select a PCP when enrolling in a plan and may request a change to their selected PCP at any time. Member-requested PCP changes will become effective the first day of the following month except in extenuating circumstances. IntegraNet contracts with certain physicians that members may choose as their PCPs and may be individual practitioners associated with a contracted medical group or an independent practice association. The PCP is responsible for referring or obtaining precertification for covered services for members. Medicare-participating PCPs are generally physicians of internal medicine, family practitioners, general practitioners, pediatricians, obstetricians/gynecologists or geriatricians. Federally qualified health centers (FQHCs) and rural health clinics (RHCs) may be included as PCPs.
The PCP is a network physician who has responsibility for the complete care of his or her members, whether providing it himself or herself or by referral to the appropriate provider of care within the network. Any referral to a provider outside of the network will require precertification from IntegraNet.
When coordinating member care, the PCP should refer the member to a participating provider within the IntegraNet network. To assist the specialty care provider, the PCP should provide the specialist with the following clinical information:
Any referral to a nonparticipating provider will require precertification from IntegraNet or the services may not be covered. Contact UM at the 281-591-5289 or 888-292-1923 for questions or more information.