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PCP Member Assignments

Date: 05/16/22

A Message for Primary Care Providers. Please share with your Administrative team.

Things to Know about Member PCP Assignments

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 to serve as a PCP.

Primary Care Provider (PCP) Responsibilities

PCPs are responsible for the provision of primary care services for Sunflower's members, including but not limited to:

  • Supervision, coordination, and provision of care to each assigned member
  • Initiation and coordination of referrals for medically necessary specialty care
  • Maintaining continuity of care & closing care gaps for each assigned member
  • Screening for behavioral health needs at each EPSDT
  • Offering days and hours of operation, appointment times, and wait times that are indistinguishable from those offered to non-Medicaid patients or patients with commercial health plan coverage

PCP Member Assignment

For members who have not selected a PCP within 10 business days of enrollment, Sunflower Health Plan will use a PCP auto-assignment algorithm, approved by KanCare, to assign a PCP for the member. The algorithm assigns members to a PCP according to the following criteria:

  • Member history with a PCP
  • If no history is present, the algorithm will assign based on a family member's history, such a sibling's history
  • Geographic proximity of PCP to member residence
  • Appropriate PCP type
  • Language need

Pregnant women should select a pediatrician or other appropriate PCP for their newborn baby before the beginning of the last trimester of pregnancy.

PCP Member Panel Capacity

The PCP to member assignment (known as a panel) ratio shall not exceed the following:

  • Physicians 1: 2,500
  • Nurse Practitioner 1: 1,250
  • Physician Assistant 1: 1,250

PCPs and specialists who want to change their panel status (open, closed, existing members only) must notify Sunflower Customer Service at 1-877-644-4623.

Dismissing a Member from Your Practice

There may be limited times when providers need to dismiss members from their practices. Use the Member Dismissal Form if you have a Sunflower member with one of these issues:

  • Member behavior - disruptive, abusive or hostile behavior toward the provider and/or office staff
  • Member fraud - suspected drug-seeking behavior
  • Chronic missed appointments - four or more missed visits in a 12-month period
  • Provider type - member does not fit the PCP's focus

Members may change their PCP at any time, with the changes becoming effective no later than the beginning of the month following the member's request for change.

For additional information, please refer to the Sunflower Provider Office Manual. Patient assignments can be found in the Secure Provider Portal and should be reviewed periodically by the provider's office.

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