1. In a managed care plan, individual who gives and coordinates members’ health care and makes referrals to specialists when necessary. 2. In TRICARE, physician who is responsible for coordinating and managing all the beneficiary’s health care unless there is an emergency.

Panel of providers focused on giving primary care services to patients of a managed care plan.

Physician (e.g., family practitioner, general practitioner, pediatrician, obstetrician/gynecologist, general internist) who sees patients first for most health problems, who oversees the care of patients in a managed health care plan (HMO or PPO), and who refers patients to specialists (e.g., cardiologist, oncologists, surgeons) for services as needed. Also known as a gatekeeper, primary care doctor, or primary care practitioner.

Health insurance company that pays on a claim as the first carrier before the second insurer pays when a patient has two policies and they are coordinating benefits.
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An original insurer as distinct from a reinsurer.

Program in which the state contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Most primary care case management (PCCM) programs pay the primary care physician a monthly case management fee in addition to reimbursing services on a fee-for-service basis. Also called primary care case management (PCCM).

Provision in an insurance policy under the coordination of benefits clause in which the health plan pays without taking into account any other plans.

1. Initial identification of the condition, illness, injury, or chief complaint for which the patient is treated for medical care in a physician’s office or as a hospital outpatient. Insurance claim forms must show the diagnostic code reflecting the primary diagnosis. 2. Underlying cause for the office visit or treatment.

Insurance company that covers the initial payments for medical services when a person has more than one health insurance plan. The patient must pay the deductible and any copayment fee.
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Insurer that provides primary Insurance. See Also: “Primary Insurance.”