If you are a Primary Care Provider (PCP), you may have encountered the following denial: “services not provided by patient’s primary care physician”. Check out the following for ways to easily avoid another of these denials.
The Medicaid program requires each recipient to be assigned to a PCP. The objective is to improve patient health care needs by providing adequate access to health care providers. To avoid experiencing this denial and help increase your overall practice revenue, simply, take the steps necessary to ensure the patient’s PCP information is updated prior to seeing Medicaid patients.
The majority of Medicaid and Medicare HMO members are required by their insurance to select a primary care physician. Reimbursement will only be allowed for the assigned PCP or an affiliated, covering and participating PCP. Particular procedures, such as office visits, will be denied if the provider is not listed as the patient’s PCP at the time of service.
Remember, always check the insurance company’s website to confirm a patient’s PCP at the time of service. PCP names listed on patients’ insurance cards are not always accurate. If the provider is not listed as the patient’s PCP, this will need to be updated prior to seeing the patient, which can be done quickly while the patient is waiting to be seen.
- NOTE: If the patient has previously been seen by your group, is coming back after a tax ID change and the card presented has the same provider name, you MUST go thru the process of PCP reassignment (changing name under new tax ID)
Many insurance companies have designed templates to help make updating a patient’s PCP information simple (see links to forms below). Submitting the forms via fax is a fast and effective way to send requests to insurance companies.
- QUICK TIP: Scan fax confirmation pages and all insurance responses into eClinicalWorks as a simple way to provide proof and allow the claim to be appealed if denied.
Click to download any of the PCP change forms below: