Policy/Procedure Number: MP PR 201 / Lead Department: Provider Relations
Policy/Procedure Title: PCP Availability and Capacity Policy and Procedure / ☒External Policy
☐ Internal Policy
Original Date: 08/12/1998 / Next Review Date:
Last Review Date: 10/10/2018
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MP PR 201 / Lead Department: Provider Relations
Policy/Procedure Title:PCP Availability and Capacity Policy and Procedure / ☒External Policy
☐Internal Policy
Original Date: 08/12/1998 / Next Review Date:
Last Review Date:10/10/2018
Applies to: / ☒Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒QUAC
☐OPerations / ☐Executive / ☐Compliance / ☐Department
Approving Entities: / ☐BOARD / ☐COMPLIANCE / ☐FINANCE / ☒PAC
☐ CEO / ☐COO / ☐Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Jeffrey Gaborko, MD / Archive Date:03/14/2018
  1. RELATED POLICIES:N/A
  1. IMPACTED DEPTS:N/A

  1. DEFINITIONS:N/A
  1. ATTACHMENTS:
  2. N/A
  1. PURPOSE:
  1. POLICY / PROCEDURE:
  2. PHC is responsible for monitoring PCP availability and capacity on an annual basis. Primary Care physicians include General and Family Practitioners, Internists, Gerontologists, Obstetrician-Gynecologists and Pediatricians. The PHC availability standard as defined below:
  3. 1 PCP office site located within 30 minutes or 10 miles of member's residence.
  4. 1:2000 = 1 Physician to 2000 members
  5. 1:1000 = 1 non-physician Medical Practitioner to 1000 members
  6. Availability
  7. PHC conducts a PCP GeoAccess® analysis on an annual basis to verify PCP office site locations based on PHC availability standards. The Provider Relations Department will be responsible for working with the PHC IT Department to complete the analysis. Once the report has been completed the results will be reviewed by the Director of Quality and Performance Improvement and Provider Relations Director. The final report will be submitted to the QUAC for recommendations.
  8. Capacity
  9. PHC conducts a Capacity Survey for each contracted PCP office, Medical Group, or Clinic on an annual basis.
  10. The Provider Relations Representative assigned to the specific PCP is responsible for ensuring the survey is completed and assist the provider with questions regarding the Capacity Survey.
  11. The Provider Relations Department will use the Capacity Calculation Software to tabulate the results.
  12. If a provider is identified with a practice that exceeds the standard, PHC will communicate it's findings and recommendations to the provider. The provider will be given an opportunity to review the documentation and validate the findings. If capacity has been reached, corrective action steps will be discussed with the practice. PHC will monitor access through member complaints, satisfaction surveys, and QI activities.
  13. If access issues are identified PHC or the PCP may request the practice enrollment status to be closed to new patients until additional practitioner(s) have been added to the office or office hours have been extended to allow more capacity.
  14. The report is reviewed by PHC staff from Provider Relations, Quality Improvement and Health Services. The final report is submitted to the PHC QUAC for review and recommendations as necessary.
  15. Cultural and Linguistics
  16. PHC continuously monitors the cultural and linguistic capabilities of the primary care network to ensure members have access to practitioners in threshold languages as defined by DHCS. The report is reviewed by appropriate PHC staff, including representatives from the Health Services, Quality Improvement, Provider Relations, and Member Services Departments. Corrective action plans may be submitted to the QUAC for review and recommendation.
  1. REFERENCES:
  2. DHCS
  3. KNOX-KEENE
  4. DMHC
  1. DISTRIBUTION:PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Provider Relations Director
  1. REVISION DATES:

05/17/01, 06/20/01, 05/15/02, 05/21/03, 06/16/04, 05/18/05, 05/17/06, 06/21/06, 05/16/07, 06/16/08, 03/18/09, 03/17/10, 03/16/11, 03/21/12, 08/15/12, 08/14/13, 09/10/14, 09/09/2015, 09/14/2016, 09/20/2017, 10/10/2018

PREVIOUSLY APPLIED TO:

PartnershipAdvantage:
MP PR #201 – 06/2006 to 01/01/2015

Healthy Kids;

MP PR #201 – 05/2006 to 09/14/2016

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