Idaho Admin. Code r. 16.03.09.564

Current through September 2, 2024

Section 16.03.09.564 - HEALTHY CONNECTIONS: PROVIDER QUALIFICATIONS AND DUTIES

01.Primary Care Providers. Primary care services may be provided by enrolled physicians, physician assistants, advanced practice registered nurses, and by care teams under those providers' direction.

02.Provider Duties. All Healthy Connections providers are responsible for delivering the services listed in Section 562 of these rules.

03.Additional Services. Healthy Connections providers may also elect to provide specific additional sets of patient-centered medical home services in exchange for increased reimbursement as described in Section 565 of these rules. The definition and provision of additional patient-centered medical home services are subject to specific requirements as defined by the Department and described in the Idaho Medicaid Provider Handbook and individual provider agreements with the Department. Additional services may include:

a. Connection to the Idaho Health Data Exchange;

b. Maintaining third-party patient-centered medical home recognition or certification;

c. Expanded patient access to services;

d. Provision of an evidence-based primary care service model that enables improved patient health outcomes;

e. Reporting clinical data to the Department to allow for assessment of provider abilities and impact of their services on patient health outcomes;

f. Coordination of transitions of care between health care settings;

g. Integration of behavioral health services; and

h. Other indicators of improved patient health outcomes associated with primary care provider abilities.

04.Provider Participation Conditions and Restrictions.

a. Provider Agreements. Each independent provider or provider organization participating in primary care case management must:

i. Sign an agreement;

ii. Enroll with the Department all primary care providers and all clinic locations participating in the Healthy Connections program; and

iii. Complete pre-enrollment requirements for participation in the Healthy Connections program as defined by the Department in the Idaho Medicaid Provider Handbook.

b. Patient Limits. A provider may limit the number of participants they manage. Subject to this limit, the provider must accept all participants who either elect or are assigned to the provider, unless disenrolled in accordance with Subsection 564.02.d. of this rule. A provider may change the participant limit effective the first day of any month. The provider must make the request in writing to the Department thirty (30) days prior to the effective date of the change.

c. Disenrollment. When the provider-patient relationship breaks down due to failure of the participant to follow the care plan or for other reasons, a provider may choose to withdraw as the participant's primary care provider effective the first day of any month. The PCP must notify in writing, both the participant and the Department thirty (30) days prior to the date of withdrawal. This advance notice requirement may be waived by the Department.

d. Record Retention. Each provider must:

i. Retain patient and financial records and provide the Department access to those records for a minimum of six (6) years from the date of service;

ii. Upon the reassignment of a participant to another PCP, the provider must transfer (if a request is made) a copy of the patient's medical record to the new PCP; and

iii. Disclose information required by Subsection 205.01 of these rules, when applicable.

e. Termination or Amendment of Provider Agreements. The Department may terminate a provider's agreement as provided in Subsection 205.03 of these rules. An agreement may be amended for the same reasons.

Idaho Admin. Code r. 16.03.09.564

Effective March 17, 2022