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 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 CareSource Medical Director. A member may submit a PCP Change Request Form to request a change in PCP.

Roles and Responsibilities

According to the Ohio Administrative Code (OAC) 5610-26-03.1(B), 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 as described in paragraph OAC 5610-26-03.1(A)(2) of the rule
  • Participating in the development of case management care treatment plans and notifying CareSource of members who may benefit from care management

A PCP shall provide:

  • Availability of a personal physician 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

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

  • Treating CareSource members with the same dignity and respect afforded to all patients
  • Identifying the member’s health needs and taking appropriate action
  • Providing phone coverage for handling patients’ calls 24/7
  • Following all referral and prior authorization policies and procedures as outlined in the NavigateProvider Manual
  • Complying with the quality standards of our health plan and the Ohio Department of Medicaid (ODM) as outlined in this manual
  • 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

Cultural Competency

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.

Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care provides guidelines for individuals and organizations to implement culturally and linguistically appropriate services: