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

CareSource adheres to the National Culturally & Linguistically Appropriate Standards (CLAS), which serve as a blueprint for health care providers and organizations to implement culturally and linguistically appropriate services. CLAS consists of 15 standards that encompass the following topic areas:

  • Principal Standard: provision of effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs
  • Governance, Leadership and Workforce
  • Communication and Language Assistance
  • Engagement, Continuous Improvement & Accountability

Network providers must ensure that:

  • Members understand that they have access to free medical interpreter services in their native language, including sign language, at no cost. TDD/TTY services are available to facilitate communication with hearing impaired members
  • Health care is provided with consideration of the members’ cultural background, encompassing race/ethnicity, language and health beliefs. Cultural considerations may impact/influence member health decisions related to preventable disease or illness
  • The provider office staff makes reasonable attempts to collect race and language-specific member data. Staff is available to answer questions and explain race/ethnicity categories to a member, to assure accurate identification of race/ethnicity for all family members
  • Treatment plans are developed based on evidence-based clinical practice guidelines with consideration of the member’s race, country or origin, native language, social norms, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation and other characteristics that may result in a different perspective or decision-making process
  • Participating providers must also meet the requirements of all applicable state and federal laws and regulations as they pertain to provision of services and care

CareSource prohibits its providers or partners from refusing to treat, serve or otherwise discriminate against an individual because of race, color, religions, national origin, sex, age, gender orientation (i.e. intersex, transgendered and transsexual) or disability. In consideration of cultural differences, including religious beliefs and ethical principles, CareSource will not discriminate against providers who practice within the permissions of existing protections in provider conscience laws, as outlined by the U.S. Department of Health and Human Services (HHS).

CareSource encourages our participating providers to visit the Office of Minority Health, Cultural Competency Resources website found at: https://thinkculturalhealth.hhs.gov/education for toolkits and educational resources. Included on the site is a free 9-credit continuing medical education (CME) course, A Physician’s Practical Guide to Culturally Competent Care. This self-directed e-learning program equips providers to better understand and treat diverse populations.

Health Equity Commitment

CareSource is dedicated to the communities we serve and to making a positive impact in the lives of our members through the elimination of health disparities, supporting internal health equity initiatives and partnering with community stakeholders to carry out this much needed work.

Our Enterprise Life Services Department is dedicated to serving marginalized communities and making a positive impact in the lives of diverse member populations.