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understanding that enrollees were: (1) responsible for obtaining
precertification for major services; (2) required to pay for the
services and to seek reimbursement from petitioner; and (3)
responsible for any charges exceeding petitioner’s fee schedule
for covered services.
E. Petitioner’s Health Plans
Petitioner generally required its enrollees to agree to
coordinate all of their medical care through a primary care
physician or PCP (family practitioners, internists,
pediatricians, and some obstetricians/gynecologists). In HMO
parlance, PCPs are commonly referred to as “gatekeepers” inasmuch
as PCPs generally oversee a patient’s medical care, particularly
a patient’s referrals to specialists known as specialty care
physicians or SCPs.
1. SelectMed
Petitioner’s SelectMed plan offered enrollees access to
physician medical groups comprising more than 1,500 individual
PCPs and SCPs. As previously mentioned, enrollees were required
to select a PCP for general medical care and for referral to a
SCP.
Petitioner compensated PCPs in Salt Lake, Davis, and Weber
Counties in Utah on a discounted fee-for-service basis settled
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