Primary Care Provider Roles & Responsibility

All Humana – 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.

Provider Types

To qualify as a PCP, a provider must practice in one of the following primary care areas:

  • General practice
  • Family practice
  • Internal medicine
  • Pediatrics
  • Obstetrics/gynecology

A specialist may only qualify as a PCP with an agreement between the member, the specialist and the Humana – CareSource medical director.

Roles And Responsibilities 

A primary care provider shall:

  • Be responsible for supervising, coordinating and providing initial and primary care to Medicaid recipients
  • Be responsible for initiating referrals for specialty care
  • Be responsible for maintaining the continuity of patient care 24 hours per day, seven days a week
  • Have hospital admitting privileges or a formal referral agreement with a primary care provider who has hospital admitting privileges

In addition, Humana – 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

PCP care coordination responsibilities include at a minimum, the following:

  • Treating Humana – CareSource members with the same dignity and respect afforded to all patients–This includes high standards of care and the same hours of operation
  • Maintaining continuity of the member’s health care
  • Identifying the member’s health needs and taking appropriate action
  • Providing phone coverage for handling patient calls 24 hours a day and seven days a week
  • Making referrals for specialty care and other medically necessary services, both in and out of network if such services are not available within the Humana – CareSource network
  • Following all referral and prior authorization policies and procedures as outlined in the PROVIDER MANUAL
  • Complying with the quality standards of Humana – CareSource and the commonwealth of Kentucky as outlined in the PROVIDER MANUAL
  • Discussing advance medical directives with all members as appropriate
  • Providing 30 days of emergency coverage to any Humana – CareSource patient dismissed from the practice
  • Maintaining clinical records, including information about pharmaceuticals, referrals, inpatient history, documentation of all PCP and specialty care services; etc., in a complete and accurate medical record that meets or exceeds the Kentucky Department of Medicaid Services’ specifications
  • Obtaining patient records from facilities visited by Humana – CareSource patients for emergency or urgent care if notified of the visit
  • Ensuring demographic and practice information is up-to-date for the provider directory
  • Arranging and referring members, when clinically appropriate, to behavioral health providers
  • Assisting with coordination of the member’s overall care, as appropriate for the member
  • Serving as the ongoing source of primary and preventive care, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for persons under the age of 21 years
  • Recommending referrals to specialists, as required
  • Participating in the development of case management care treatment plans and notifying Humana – CareSource of members who may benefit from case management

Cultural Competency 

Humana – CareSource’s standard of care for members includes the removal of language barriers and the accommodation of unique ethnic, cultural and social needs of patients. That’s why we ask that all contracted health care professionals work to eliminate those barriers and comply with applicable state and federal laws.

Below is a listing of resources related to Culturally and Linguistically Appropriate Services (CLAS) and the Department of Health and Human Services website to better assist you in maintaining compliance with this requirement: