Primary Care Services
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
The primary care physician (PCP) is responsible for the management and coordination of a member's medical care, including initial and primary care, maintaining continuity of care, and initiating specialist referral. The PCP refers the member to a specialist when additional knowledge or skills are required.
Health Net has delegated the referral process to some participating physician groups (PPGs). Referrals to participating and non-participating specialists for capitated members are subject to any additional rules imposed by the PPG. PPGs may not impose referral or authorization requirements that conflict with the member's right to self-refer for services.
Listed below are examples of services that are considered primary care services. A PCP is expected to have the expertise necessary to perform most of these services. The PCP must have received relevant training within the limitations of scope of practice that is consistent with state and federal rules and regulations. These guidelines are based on routine, uncomplicated cases where care is provided by a PCP. This list provides guidelines, is not intended to be all-inclusive, and should be used with discretion.
Allergy
- Treat seasonal allergies
- Treat hives
- Treat chronic rhinitis
- Allergy history
- Environmental counseling
- Minor insect bites and stings
- Asthma, active with or without co-existing infection
- Allergy testing and institute immunotherapy (if trained)
- Administer immunotherapy
Adult Cardiology
- Perform electrocardiograms
- Interpret electrocardiograms
- Evaluate chest pain
- Evaluate and treat coronary risk factors, including smoking, hyperlipidemias, diabetes, and hypertension
- Evaluate and treat uncomplicated hypertension, CHF, stable angina, non-life-threatening arrhythmias
- Evaluate single episode syncope (cardiac)
- Evaluate benign murmurs and palpitations
Dermatology
- Treat acne - acute and recurrent
- Treat painful or disabling warts with topical suspensions, electrocautery and liquid nitrogen
- Diagnose and treat common rashes, including contact dermatitis, dermatophytosis, herpes genitalis, herpes zoster, impetigo, pediculosis, pityriasis rosea, psoriasis, scabies, seborrheic dermatitis, and tinea versicolor
- Screen for basal or squamous cell carcinomas
- Biopsy suspicious lesions; if trained, may do biopsy of suspicious lesions for cancer or others, such as actinic keratoses
- Punch biopsy
- Incisional biopsy
- Diagnose and treat common hair and nail problems and dermal injuries
- Common hair problems include fungal infections, ingrown hairs, virilizing causes of hirsutism, or alopecia as a result of scarring or endocrine effects
- Common nail problems include trauma, disturbances associated with other dermatoses or systemic illness, bacterial or fungal infections, and ingrown nails
- Dermal injuries include minor burns, lacerations, and treatment of bites and stings
- Counsel members regarding removal of cosmetic (non-covered) lesions
- Identify suspicious moles
Endocrinology
- Diabetic management, including type I and type II for most members
- Member education
- Supervision of home (SBGM) testing
- Medication management
- Manage DKA
- Manage thyroid nodules (testing, scans, ultrasound)
- Diagnose and treat thyroid disorders
- Identify and treat hyperlipidemia
- Diet instruction
- Exercise instruction
- Provide member education for osteoporosis risk factors
- Identify and treat lipid disorders with diet and/or at least two medications for a minimum of six months
Gastroenterology
- Diagnose and treat lower abdominal pain
- Diagnose and treat acute diarrhea
- Occult blood testing
- Perform flexible sigmoidoscopy
- Diagnose and treat heartburn, upper abdominal pain, hiatal hernia, acid peptic disease
- Evaluate acute abdominal pain
- Diagnose and treat uncomplicated inflammatory bowel disease
- Diagnose jaundice
- Diagnose and treat ascites
- Diagnose and treat symptomatic, bleeding or prolapsed hemorrhoids
- Manage functional bowel disease
- Manage diagnosed malabsorption syndrome
- Manage mild hepatitis A
General Surgery
- Evaluate and follow small breast lumps in teenagers
- Order screening mammograms
- Aspirate cysts
- Foreign body removal
- Laceration repairs (minor)
- Local minor surgery for hemorrhoids
- Minor surgical procedures
- Diagnose gallbladder disease
- Manage inguinal hernia
Geriatrics
- Diagnose and treat impaired cognition (dementia)
- Be familiar with effects of aging on medication distribution, metabolism and interaction
- Management of advanced illness including the use of alternative levels of care
- Recognition of elder abuse
Gynecology/Obstetrics
- Perform routine pelvic exams and Pap smears
- Perform lab testing for sexually transmitted diseases
- Wet mounts
- Diagnose and treat vaginitis and sexually transmitted diseases
- Contraceptive counseling and management
- Normal pregnancy (if physician privileged to deliver)
- Evaluate lower abdominal pain to distinguish gynecological from gastrointestinal causes
- Diagnose irregular vaginal bleeding
- Diagnose and treat endometriosis with hormone therapy
- Manage premenstrual syndrome with non-steroidal anti-inflammatory hormones and symptomatic treatment
Neurology
- Diagnose and treat all psychophysiological diseases, headaches, low back pain, myofascial pain syndromes, neuropathies, radiculopathies, and central nervous system disorders
- Diagnose and treat tension and migraine headaches
- Order advanced imaging procedures (MRI or CT scan at an appropriate anatomic level after an appropriate clinical evaluation and trial of conservative therapy
- Diagnose and management of syncope
- Treat seizure disorders
- Manage degenerative neurological disorders with respect to general medical care (for example, Parkinson's)
- Manage stroke and uncomplicated TIA members
- Lumbar puncture
- Treat myofacial pain syndromes
Ophthalmology
- Perform thorough ophthalmologic history including symptoms and subjective visual acuity
- Perform common eye-related services
- Distant/near vision testing
- Color vision testing
- Gross visual field testing by confrontation
- Alternate cover testing
- Direct funduscopy without dilation
- Extraocular muscle function evaluation
- Red reflex testing in pediatric members
- Remove corneal foreign bodies (except metallic)
- Treat corneal abrasions
- Perform tonometry
- Diagnose and treat common eye conditions:
- Viral, bacterial and allergic conjunctivitis
- Blepharitis
- Hordeolum
- Chalazion
- Subconjunctival hemorrhage
- Dacryocystitis
Orthopedics
- Treat low back pain and sciatica without neurological deficit
- Treat sprains, strains, pulled muscles, overuse symptoms
- Treat acute inflammatory conditions
- Chronic knee problems
- Manage chronic pain problems
- Diagnose and treat common foot problems: ingrown nails, corns, callouses, bunions
- Closed emergency reduction of dislocation: digit, patella, shoulder
- Treatment of minor fractures
- Arthrocentesis
Otolaryngology
- Treat tonsillitis and streptococcal infections
- Perform throat cultures
- Evaluate and treat oropharyngeal infections
- Stomatitis
- Herpangina
- Herpes simplex
- Treat acute otitis media
- Treat effusion
- Evaluate tympanograms/audiograms
- Treat acute and chronic sinusitis
- Treat allergic or vasomotor rhinitis
- Remove ear wax
- Treat nasal polyps
- Diagnose and treat acute parotitis and acute salivary gland infections
- Treat nasal obstruction (including foreign body)
- Treat simple epistaxis
Physical Medicine and Rehabilitation
- Coordinate care for members recovering from major trauma or CNS injury by appropriate use of various rehab professionals including PT, OT, ST, and physiatrist
- Basic understanding of effective use of common orthotic and prosthetic devices including wrist splint for CTA and AFO for foot drop
Psychiatry
- Perform complete physical and mental status examinations and extended psychosocial and developmental histories when indicated by psychiatric or somatic presentations (fatigue, anorexia, overeating, headaches, pains, digestive problems, altered sleep patterns, and acquired sexual problems)
- Diagnose physical disorders with behavioral manifestation
- Provide maintenance medication management after stabilization by a psychiatrist or if longer-term psychotherapy continues with a non-physician therapist
- Diagnose and care manage child, elder, dependent adult abuse, and domestic violence victims
Pulmonology
- Diagnose and treat asthma, acute bronchitis, pneumonia
- Diagnose and treat chronic bronchitis
- Diagnose and treat chronic obstructive pulmonary disease (COPD)
- Manage home aerosol medications and oxygen
- Work up possible tuberculosis or fungal infections
- Treat opportunistic infection
- Order chest X-rays, special views and CT scans
Rheumatology
- Diagnose and treat non-articular musculoskeletal problems:
- Overuse syndromes
- Injuries and trauma
- Soft tissue syndromes
- Bursitis or tendonitis
- Provide steroid injections
- Manage osteoarthritis unless there is a significant functional impairment despite treatment
- Diagnose crystal diseases
- Perform arthrocentesis
- Diagnose and treat rheumatoid arthritis
- Diagnose and treat inflammatory arthritic diseases
- Diagnose and treat uncomplicated collagen diseases
Urology/Nephrology
- Diagnose and treat initial and recurrent urinary tract infections
- Provide long term chemoprophylaxis
- Diagnose and treat urethritis
- Explain hematospermia
- Initiate evaluation of hematuria
- Evaluate incontinence
- Evaluate male factor infertility and impotence and treat readily correctable factors
- Diagnose and treat epididymitis and prostatitis
- Differentiate scrotal or peritesticular masses from testicular masses
- Evaluate prostatism and prostatic nodules
- Manage urinary stones
- Evaluate and treat renal failure
- Placement of urinary catheters
- Evaluate impotence
- Evaluate male infertility
Vascular Surgery
- Diagnose abdominal aortic aneurysm
- Diagnose and treat venous diseases
- Treat stasis ulcers
- Manage intermittent claudication
- Manage transient ischemic attacks
- Manage asymptomatic bruits
Other
- Basic life support
- Advanced life support
- Heimlich maneuver
- Endotracheal intubation
- Tracheostomy (emergency)
Hospital Procedures
- Hospital admissions and daily care
- Hospital consultations
- Pre-operative history
- Newborn evaluation and nursery care
Infectious Disease
- Human immunodeficiency virus (HIV)
- AIDS