Primary Medical Provider Roles & Responsibility
All CareSource® members choose or are assigned a primary medical provider (PMP) upon enrollment in the plan.
PMPs should help facilitate a medical home for members. This means that PMPs 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 provided below.
To qualify as a PMP, a provider must practice in one of the following primary care areas:
- General practice
- Family practice
- Internal medicine
- Endocrinology (if primarily engaged in internal medicine)
- Certified nurse practitioner
Indiana Health Coverage Programs (IHCP) has also published Provider Enrollment guidance.
If a member does not select a PMP, CareSource will assign one. Providers may submit the Member Reassignment Form to request a change in PMP for the member.
Roles And Responsibilities
PMP 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
- Providing care that addresses the needs of Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) members in an integrated way, with attention to the physical health and chronic disease contributions to behavioral health
- Providing a written plan and evidence of ongoing, increased communication between the PMP, CareSource and the behavioral health provider
- Coordinating management of utilization of behavioral health care services with Medicaid Rehabilitation Option (MRO) and 1915(i) services and services for physical health
In addition, CareSource PMPs 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
PMPs 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.
- Identifying the member’s health needs and taking appropriate action
- Providing phone coverage for handling patients’ calls 24 hours a day, 7 days a week
- 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 Indiana Office of Medicaid Policy and Planning
- Providing 30 days of emergency coverage to any CareSource patient dismissed from the practice
- 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
- Reporting suspected fraud and/or abuse
- Providing “live voice” coverage after normal business hours which may include an answering service or shared-call system with other providers
- Ensuring members’ telephone access to their PMP in English and Spanish 24 hours a day, 7 days a week
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.
- CareSource encourages our participating providers to visit the Office of Minority Health Cultural Competency website at https://thinkculturalhealth.hhs.gov/education for educational resources and tool kits. Included on the site is a free nine-credit continuing medical education (CME) course, A Physician’s Practice Guide to Culturally Competent Care. The self-directed e-learning program equips providers to better understand and treat diverse populations.