This CMS standard provides:

The MAO establishes, maintains, and monitors a panel of primary care providers from which the member may select a personal primary care provider.

In addition to a URAC standard that essentially repeats the CMS standard, as well as a core consumer communications practices standard covered elsewhere, URAC supports the standard with MAP-NM 11:

The Basics

This standard requires that your organization, if it requires consumers to get a referral in order to see a specialist, either assign a PCP to the consumer or make other arrangements as necessary so that the consumer has access to medically necessary specialty healthcare.  Typically, health plans have a policy and procedure that creates a mechanism to encourage consumers to select a PCP during or shortly after enrollment, and, after a certain period of time, appoint a PCP if the consumer does not select one.  It is possible that your organization may take a different approach, so make sure you are familiar with the particular approach your organization takes to assuring specialty care.

Management Tips

kept the standard get your organization a lot of flexibility.  What there is not flexibility around is that your policies and procedures be explicit in how you handle this issue of access to specialty care, whether through PCP referral or other mechanisms.  In addition, because your staff is likely to be interviewed on this topic, and staff members need to be fully trained and whatever mechanisms you install for access to specialty care.

URAC Accreditation Tips

During the desktop review phase, submit sample provider contracts, policies and procedures, and/or applicable sections from your provider manual and member handbook that described how a consumer is supposed to access specialty care.  URAC also recommends that you submit results from consumer satisfaction surveys and provider profile report cards, particularly if they provide information about over-and under-utilization.

The on-site interview will be directed at customer service and provider relations staff members, and will cover such specialty referral issues as your organization's policy regarding access to women's health services.  In addition, questions are likely to arise around the conditions under which a consumer goes to a non--participating provider in the absence of an available specialty provider.  The on-site document review will be an examination of any examples of out-of-network referrals were specialists were not available within the network.