Primary Care Provider Roles & Responsibility

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Primary Care Managers

All TRICARE Prime® Demo by CareSource Military & Veterans™ beneficiaries will be assigned or may choose a Primary Care Manager (PCM) upon enrollment in the plan. PCMs should help facilitate a medical home for beneficiaries. This means that PCMs will help coordinate health care for the beneficiary and provide additional health options to the beneficiary for self-care or care from community partners.

Beneficiaries select a PCM from our online Provider Directory available at CareSourceMilitary.com > Members/Beneficiaries > Tools & Resources > Find a Doctor. Beneficiaries have the option to change to another network PCM as often as needed. Beneficiaries initiate the change by calling Beneficiary Services, using the MyLife portal, or using the MyLife mobile app.

Primary Care Manager Roles and Responsibilities

PCM care management responsibilities include at a minimum, the following:

  • Assisting with coordination of the beneficiary’s overall care, as appropriate for the beneficiary.
  • Serving as the ongoing source of primary and preventive care.
  • Connecting beneficiaries to specialists, as required.
  • Triaging beneficiaries.
  • Participating in the development of case management care treatment plans and notifying TRICARE Prime Demo of beneficiaries who may benefit from case management. Please see the “Beneficiary Support Services and Benefits” section of this manual to learn how to refer beneficiaries for case management.

PCMs are Responsible For:

  • Treating beneficiaries with the same dignity and respect afforded to all patients. This includes high standards of care and the same hours of operation.
  • Identifying the beneficiary’s health needs and taking appropriate action.
  • Providing phone coverage for handling patient calls 24 hours a day, seven days a week.
  • Following all prior authorization policies and procedures as outlined in this manual.
  • Complying with the quality standards of our health plan providing 30 days of emergency coverage to any TRICARE Prime Demo patient dismissed from the practice.
  • Maintaining clinical records, including information about pharmaceuticals, inpatient history, etc.
  • Obtaining patient records from facilities visited by TRICARE Prime Demo patients for emergency or urgent care if notified of the visit.
  • Use best commercial efforts to collect required copayments for services rendered to applicable beneficiaries.
  • Ensuring demographic and practice information is up to date for directory and beneficiary use.
  • Reporting suspected fraud and/or abuse.
  • PCMs disenrolling from TRICARE Prime Demo must provide continuation of care for TRICARE Prime Demo beneficiaries for a minimum of thirty (30) calendar days or until the beneficiary’s link to another PCM becomes effective.

In addition, TRICARE Prime Demo PCMs play an integral part in coordinating health care for our beneficiaries by providing:

  • Availability of a personal health care practitioner to assist with coordination of a beneficiary’s overall care, as appropriate for the beneficiary.
  • Continuity of the beneficiary’s total health care.
  • Early detection and preventive health care services.
  • Elimination of inappropriate and duplicate services.