Agreement For Participation Template - Department Of Vermont Health Access Page 2
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44. DVHA will maintain a provider relation function for participating providers.
5. DVHA will incorporate its Drug Utilization Review (DUR) functions into the program.
6. DVHA will perform Prior Authorization and Utilization Review functions for specific services and items.
7. DVHA will administer the PCCM program’s enrollment functions.
B. The following specifies the responsibilities of each provider who serves as a PCP.
1. Each PCP will remain an active Medicaid provider while serving in the PCCM program. Each PCP will
return the Medicaid recertification form within the time allotted. Failure to do so may result in the forfeit
of the PMPM payment until the enrollment is updated.
2. For referrals, the PCP will use Medicaid participating providers, or providers enrolled to serve
beneficiaries enrolled in the PCCM program, unless the required service is not otherwise available from a
currently enrolled Medicaid provider. If the PCP wants to use a provider that is not enrolled, HP Provider
Services should be notified to solicit the enrollment of the provider.
3. The PCP or PCP‘s practice will maintain office visiting hours at least four days per week for at least
twenty-five hours per week for enrollee appointments, unless this provision is waived by DVHA if
necessary to assure access to services and providers. Participating PCPs who work in a practice on a part-
time basis will inform DVHA of the times they are available to see patients.
4. The PCP will assure that all enrollees have a current medical history and record, and will maintain
medical records for each enrollee.
5. If released by the Medicaid enrollee, the PCP will secure the enrollee’s medical record from the previous
PCP, and other providers necessary to ensure that the PCP has a comprehensive understanding of the
enrollee’s needs and that the enrollee receives all medically necessary care.
6. The PCP will make best efforts to offer to examine each new enrollee to the PCP’s practice within three
months. Scheduling this examination will be subject to the agreement of the enrollee, and at a mutually
available time for the enrollee and PCP.
7. The PCP agrees to the appointment waiting times standards set out in Rule 10, promulgated by the
Department of Banking, Insurance, Securities, and Health Care Administration (BISHCA). These
appointment standards are that generally an enrollee should be seen within: 24 hours for urgent care, two
weeks for non-urgent care, and 90 days for preventive and routine physical examinations.
8. The PCP will provide all covered primary services consistent with the PCP’s qualifications and will make
appropriate referrals to specialist as necessary.
9. The PCP will have provisions for access to a 24-hour on-call group that will assure practitioner
availability in person or by phone.
10. The PCP will assure that any children or adolescents enrolled with the PCP are screened according to the
requirements of the Vermont Department of Health’s EPSDT periodicity schedule.
8-1-2012
Page 2
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