Primary Care Provider (PCP)

The medical home is central to the integrated model of care delivery designed for the STAR Health population.  Primary Care Providers serve as that medical home and function as the clinical driver of appropriate health care services to support each patient. The “medical home” concept should assist in establishing a Member/Provider relationship and ultimately lead to better health outcomes. As a medical home, the PCP works with Members, Medical Consenters, Caregivers, other Providers, Superior Service Managers and Coordinators and other state and non-state entities to assure that all the Member’s medical and behavioral health needs are met. This includes screening, identification, referrals and/or authorizations for medically necessary services, assessments and coordination of non-clinical services that impact the Member’s health.

Who Can Serve as a PCP?

Credentialed Providers in the following specialties can serve as a PCP:

• Family Practice

• General Practice

• Internal Medicine

• Pediatrician

• OB/GYN

• Physician Assistant

• Nurse Practitioner

• Specialist (*See below – Specialist as PCP)

Specialist as PCP

Superior allows Members with chronic, disabling, or life-threatening illnesses to apply to Superior’s Medical Director to utilize a physician contracted and designated as a Specialist, as their PCP.

To be eligible to serve as a PCP, the Specialist must meet Superior HealthPlan Network’s requirements for PCP participation, including credentialing, and must contract with Superior as a PCP.

Superior will approve or deny the request for a Specialist to serve as a PCP and provide notification of the decision to the Member no later than 30 days after receiving the request.

If the request is denied, Superior will provide in the written notification to the Member, the reasons for the denial of the request. The Member may appeal the decision to deny the request for Specialist as PCP through the Superior’s Member complaint and appeal process.

When a Specialist is approved as a PCP, Superior will provide the non-PCP Specialist with a current directory of participating Providers.