Definition - primary care physician, QIO, specialist physician, subscriber

“Primary Care Physician (PCP)” means a Participating Physician who supervises, coordinates

and provides primary care services to Enrollees, including the initiation of their referral for specialist services and other non-PCP services, and who meets all the other requirements for PCP contained in CAREPLUS’ rules and regulations and in the Primary Care Physician Agreement. Also referred to as “PCP”.

“Primary Care Services” means Covered Services customarily provided by a PCP in his or her office as well as services customarily provided by an attending PCP to institutionalized patients.

This includes, by way of example and not limitation, the primary care services as set forth in

Attachment “A” of the PCP Agreement.

“QIO (Quality Improvement Organization)” means an Organization comprised of practicing doctors and other health care experts under contract to the Federal government to monitor and improve the care given to Medicare enrollees. QIOs review complaints raised by enrollees about the quality of care provided by physicians, inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Medicare health plans, and ambulatory surgical centers. The QIOs also review continued stay denials for enrollees receiving acute inpatient hospital facilities as well as coverage terminations in SNFs, HHAs and CORFs.

“Special Needs Plan” or “SNP” were created by Congress in the Medicare Modernization Act (MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or disabling chronic conditions. SNPs offer the opportunity to improve care for Medicare beneficiaries with special needs by through improved coordination and continuity of care and by combining benefits available through Medicare and Medicaid.

“Specialist Physician” means a Participating Physician who is Board Certified or has met the academic requirements to sit for the Board in a certain medical specialty; who provides services to Enrollees within the range of such specialty; who elects to be designated as a Specialist Physician by CAREPLUS; and who meets all other requirements for Specialist Physicians contained in CAREPLUS’ rules and regulations and in the Agreement between CAREPLUS and the Specialist Physician.

“Specialist Services” means those services of a Specialist Physician, within the scope of his/her Board Certified or Board Eligible specialty, that are:

(1) provided upon the referral of a PCP pursuant to CAREPLUS’ rules and regulations;

and

(2) Covered Services, but not PCP Services.

“Subscriber” means any individual who has entered into a Subscriber Agreement with CAREPLUS directly or through his or her employer for the provision of Covered Services. Dependents that are eligible to receive Covered Services under CAREPLUS’ applicable Subscriber Agreement shall be considered as Enrollees. 

“Urgent Care” means care provided for those problems which, though not life-threatening, could result in serious injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe pain) or do substantially restrict a Member’s activity (e.g., infectious illnesses, flu, respiratory ailments, etc.)