IHC Health Plans, Inc. - Page 20

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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              
               Petitioner compensated PCPs in Salt Lake, Davis, and Weber             
          Counties in Utah on a discounted fee-for-service basis settled              

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Last modified: May 25, 2011