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Back  RFI # 977: 1.4.7.1 # 5 PCP if applicable

Formal vs. Informal Help Informal Formal

Submitter

Boyle-Campbell Donna

Description

Item 1.4.7.1 on page 20 of 005010X279 requires Primary Care Provider be returned, if applicable.
If the inquiry is being made by the member's PCP/HMO provider, I would assume this means that the "if applicable" piece would apply and it's therefore not required to return the PCP/HMO provider if they/he/she is doing the inquiry.
Is the intent of this requirement to return the Primary Care Provider to identify that there is one, regardless of whether or not the PCP is doing the inquiry OR is the intent to only return the Primary Care Provider when the assigned Primary Care Provider is not the one doing the inquiry and must be made aware there is a PCP?

Submitter Assigned Keywords

PCP

Response

The Primary Care Provider must always be returned if there is a PCP assigned to the patient regardless of who is making the inquiry. If the PCP makes the inquiry and they are identified as the PCP, it is confirmation that they are the PCP or it would indicate that the information receiver is not the PCP of record. Since individuals can change PCPs at their discretion, it is important to always return the PCP regardless of who makes the inquiry.

Recommendation

While the PCP is required as part of 005010X279, the concept is related to any gateway provider, regardless of that provider being a “PCP” or an “HMO” provider. It is recommended that the HMO provider information is also returned.
Submission 3/1/2010
Status Date 7/30/2010
Status F - Final
Primary References
Document 005010X279
Section1.4.7.1
Page20
Set ID271
Table2
Loop2120
Segment Position3400
Segment IDNM1