Primary Care Provider Roles & Responsibility
All CareSource® members choose or are assigned a primary care provider (PCP) upon enrollment in the plan.
PCPs should help facilitate a medical home for members. This means that PCPs will help coordinate health care for the member and provide additional health options to the member for self-care or care from community partners.
In addition, providers are expected to administer patient care in a culturally competent manner. Resources are provide below.
To facilitate total care integration for our members, CareSource encourages a medical home care model. A medical home is a long-term partnership between the PCP/provider team, the patient and the patient’s family. The care model focuses on the whole patient, with support and advice for prevention, behavioral health and dental health. The model provides many benefits to the member and provider, including fewer hospital/ER visits, higher patient satisfaction, improved access for members in rural environments and higher quality at a lower cost to the health care system. Members with a behavioral health diagnosis may select a behavioral health home in addition to their PCP.
CareSource encourages providers to attain National Committee on Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition. We will offer tiered financial incentives for providers who have NCQA PCMH recognition. To support providers working to attain NCQA PCMH accreditation, CareSource offers free consultative assistance to navigate the recognition process with NCQA.
CareSource supports the ongoing relationship between our network dentists and our members. We want to ensure our members have access to a full array of dental services that deliver appropriate and timely dental care. We offer eligible members access to a comprehensive dental network across the state of Georgia that leverages the model of a “health home” to organize and coordinate access to dental care for all of our qualified populations. Our dental home model is inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way.
We have partnered with Scion to provide a comprehensive network of dental providers. The Scion Dental Provider Portal provides time-saving features to view member eligibility, view authorization guidelines and submit authorizations and claims. Email the web portal team or call 1-855-434-9239 for any questions.
For member eligibility verification and dental history (including the specific tooth and four surface areas to all dental procedure codes), you may also visit the CareSource Provider Portal.
A member may select a primary care provider (PCP) as a medical home from the following types of providers:
- Family practice physicians
- General practice physicians
- Pediatricians, for members up to age 19
- Internal medicine
- Obstetricians and gynecologists (optional)
- Nurse practitioners certified (NP-C) specializing in:
- Family practice; or
Note: NP-Cs in independent practice must also have a current collaborative agreement with a licensed physician who is a network provider, who has hospital admitting privileges and who oversees the provision of services furnished by NP-Cs.
- Psychiatrists who agree to serve as PCPs for members who have a primary diagnosis of Severe Persistent Mental Illness
- Physicians who provide medical services at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).
- Providers who practice at public health department clinics and hospital outpatient clinics when the majority of their practice is devoted to providing continuing comprehensive and coordinated medical care
- Physician assistants (physician will be listed as member’s PCP)
- Retail health clinics, such as Walmart, Little Clinics, CVS and Walgreens
- Specialists treating members’ chronic conditions and who agree to act as their PCPs
Roles And Responsibilities
PCP care coordination responsibilities include at a minimum, the following:
- Assisting with coordination of the member’s overall care, as appropriate for the member
- Serving as the ongoing source of primary and preventive care
- Recommending referrals to specialists, as required
- Triaging members
- Participating in the development of case management care treatment plans and notifying CareSource of members who may benefit from care management
In addition, CareSource PCPs play an integral part in coordinating health care for our members by providing:
- Availability of a personal health care practitioner to assist with coordination of a member’s overall care, as appropriate for the member
- Continuity of the member’s total health care
- Early detection and preventive health care services
- Elimination of inappropriate and duplicate services
PCPs are responsible for:
- Treating CareSource members with the same dignity and respect afforded to all patients. This includes high standards of care and the same hours of operation.
- Providing preventive care and teaching healthy lifestyle choices.
- Assessing the urgency of members’ medical needs and directing members to the best place for that care.
- Identifying members’ health needs and taking appropriate action.
- Providing phone coverage for handling patient calls 24 hours a day, 7 days a week.
- Making referrals to medical specialists when necessary.
- Following all referral and prior authorization policies and procedures as outlined in the Provider Manual.
- Complying with the quality standards of our health plan and the Georgia Department of Community Health (DCH).
- Maintaining clinical records, including information about pharmaceuticals, referrals, inpatient history, etc.
- Obtaining patient records from facilities visited by CareSource patients for emergency or urgent care, if notified of the visit.
- Ensuring demographic and practice information is up to date for directory and member use.
Providers are expected to provide services in a culturally competent manner, which includes removing all language barriers to service and accommodating the unique ethnic, cultural and social needs of the member. Providers must also meet the requirements of all applicable state and federal laws and regulations.
The CareSource Cultural Competency Plan outlines our commitment to providing culturally-competent services to our members. In addition, Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care provides guidelines for individuals and organizations to implement culturally and linguistically appropriate services:
- Compendium of State-Sponsored National CLAS Standards Implementation Activities– Review state governments’ implementation of CLAS standards.
- CLAS Training Webinar– Learn more about the fundamentals of national CLAS standards.
- CLAS in Action Training Webinar– Dive deeper into implementing national CLAS standards into how you care for patients.
- Department of Health And Human Services – Visit the HHS website for more training on cultural competency.