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Sunflower Medicaid Primary Care Physician (PCP) Member Assignment

Date: 07/15/20

From time to time, providers may need to help coordinate the assigned primary care physician (PCP) for a member. Sunflower members must initiate or approve any change in their PCP.

Members always have the opportunity to select their PCP of preference. Consider these recommendations with your interactions with members you serve:

  • Encourage the member to identify a PCP, if not already identified.
  • Encourage the member to talk to their PCP about their healthcare needs.
  • Encourage the member to contact their PCP for check-ups, including preventative care and immunizations.
  • Pregnant women should select a pediatrician or other appropriate PCP for their newborn baby before the beginning of the last trimester of pregnancy. In the event that the pregnant member does not select a PCP, Sunflower will auto-assign* one for her newborn.

The member may change PCPs at any time, with the change becoming effective no later than the beginning of the month following the member’s request for change. The member can request a change through the member portal or by calling Customer Service at 1-877-644-4623, OR a provider’s office can fax us a PCP Change Request form signed by the member. 

PCP change forms are available in both English and Spanish on our Manuals, Forms & Resources page.

Provider Types That May Serve as PCPs

Primary care physicians are defined as physicians with a primary specialty designation of family medicine, general internal medicine, pediatric medicine or a subspecialty related to those specialties. Advanced practice clinicians under the personal supervision of an eligible physician may also be eligible and reimbursed at 75 percent of the increased rate. Increased payments do not apply to Rural Health Clinic and Federally Qualified Health Center services.

PCPs are responsible for the provision of primary care services for Sunflower’s members.  For a list of some of those responsibilities please see the Provider Manual.

Reminder: Appointment Availability and Wait Times for PCPs

  • Regular: members are seen within 3 weeks.
  • Urgent: members are seen within 48 hours.

* Sunflower uses an algorithm approved by KanCare to auto-assign members to a PCP according to the following criteria, and in this sequence:

  1. Member history with a PCP. The algorithm will first look to see if the member is a returning member and attempt to match him or her to his or her previous PCP. If the member is new to Sunflower, claim history provided by the state will be used to match the member to a PCP that the member had a previous relationship with, where possible. If the member joins Sunflower and is already established with a provider who is not part of the network, Sunflower will make every effort to arrange for the member to continue with the same provider if the member so desires.
  2. If the member has no previous relationship with a PCP, the algorithm will try to assign a PCP listed for someone in the member’s family, such as a sibling.
  3. Geographic proximity of PCP to member residence. The auto-assignment logic will ensure members travel no more than 30 miles or 45 minutes in rural areas or 20 miles or 40 minutes in urban areas.
  4. Appropriate PCP type. The algorithm will use age, gender, and other criteria to ensure an appropriate match, such as children assigned to pediatricians.
  5. Language Need. The algorithm will take into consideration any language need(s) of the member.

If you have questions about this bulletin or other provider resources, please contact Customer Service at 1-877-644-4623.