MEDICAID HEALTH PLAN PROVIDER NETWORK CHECKLIST
Worksheet for __ Initial Survey __ Expansion/Enrollment Increase __ Comprehensive Survey
PLAN: ______COUNTY: ______
Date Reviewed: ______/______/______Maximum Enrollment Level: ______
Surveyor Name(s): ______
CONTRACT REQUIREMENTS NUMBER
COMPLETE INCOMPLETE COMMENTS
PRIMARY CARE PHYSICIANS:ACCESS: Primary care physicians are within 30 minutes travel time of service.
1 PCP/1500 members
(can increase ratio by 750/each FTE ARNP or PA)
PCP - Family Practice or General
Practice
(Must have at least 1 FTE/
county)
PCP - Internal Medicine
(Must have at least 1 FTE/
county)
PCP - Pediatrics
(Must have at least 1 FTE/
county)
Number of PCPs needed is determined by dividing the number of Enrollees by 1500. / Total number of PCPs need for county _____
INPATIENT SERVICES:
ACCESS: Contract acute care hospital services are within 30 minutes travel time for service area residents.
Hospital (1 bed/275 members)
Number of beds needed determined by dividing number of Enrollees by 275
/ Total number of hospital beds needed for county____
Are Pediatric beds available?______
Birth Delivery Facility or Hospital with birth delivery facilities.
Birthing Center
RPICC or NICU Level 3
24 hour emergency services facility w/in 30 minutes average travel time
Licensed Pharmacy/Pharmacist
CONTRACT REQUIREMENTS NUMBER
COMPLETE INCOMPLETE COMMENTS
SPECIALTY PHYSICIANS;ACCESS; Specialty physicians are within 60 minutes travel time for service area residents.
Adolescent Medicine
Allergist
Anesthesiologist2
Cardiologist1
Cardiovascular Surgeon1
Certified Nurse Midwife/Licensed Midwife
Chiropractor
Dermatologist
Endocrinologist1
Gastroenterologist
General Surgery
Infectious Disease/Aids Specialist
Nephrologist1
Neurologist1
Neurosurgeon
Obstetrics/Gynecology
Oncologist
Opthalmologist
Optometrist
Oral Surgeon
CONTRACT REQUIREMENTS NUMBER
COMPLETE INCOMPLETE COMMENTS
Orthopedic Surgeon1Orthopedist1
Otolaryngologist
Pathologist2
Podiatrist
Psychiatrist
Pulmonologist
Radiologist2
Rheumatologist
Therapist - Occupational1
Therapist - Physical1
Therapist - Respiratory1
Therapist - Speech1
Urologist
Durable Medical Equipment
Home Health Services
Laboratory Services
Portable X-ray Services
Freestanding Dialysis Centers
Dental Services
Hearing Services
Vision Services
Transportation
School-based services (only in counties in which school-based services exist)
Contract or Good faith effort
County Public Health Departments
Contract or Good faith effort
1 ADULT AND PEDIATRIC SPECIALISTS ARE REQUIRED
2 SPECIALISTS MAY BE HOSPITAL BASED
ADDITIONAL NETWORK PROVIDERS # COMMENTS
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