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What are my responsibilities as a HMO provider?

Physician/health care provider roles and responsibilities differ among the various specialties; however, certain responsibilities will be shared by all HMO-contracted physicians and providers.

The responsibilities of HMO-contracted physicians/providers include, but are not limited to the following:

  • Providing and coordinating health care for the enrollee.
    - Contracted primary care physicians (PCP's) are responsible for managing the enrollee's primary, preventative, acute and chronic health care needs, for initiating specialist referrals and for obtaining any required pre-authorizations.
    - Contracted referral specialists are responsible for providing covered health care services to the enrollee and for ensuring that any required referrals have been obtained.
  • Hold Harmless clause in contract.
    - A HMO physician/provider contract must include a statement that the physician/provider will not bill the enrollee for payment of the cost of covered health care services (hold harmless), if the HMO does not pay for those services, with the exception of applicable co-payments.
  • Posting the required notice to enrollees of the process for resolving complaints with the HMO.
  • Maintaining current and accurate patient records and protecting them in a manner consistent with all applicable confidentiality-related requirements.
    - Also, if required by the HMO, retain updated information concerning patient's other health benefit plan coverage, if any.
  • Knowing what your contract requires of you.

Referrals

In most HMO plans the enrollee's primary care physician (PCP) is responsible for managing the enrollee's primary, preventative, acute and chronic health care needs and for initiating any required specialist referrals.

HMO-contracted specialists are also responsible for providing covered health care services and for coordinating the enrollee's health care, which may include the reporting of the enrollee's medical status to the referring healthcare provider and/or the HMO.

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Last updated: 03/25/2015

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