Pharmacist Provider Status

Pharmacists may register as a CareSource Provider and bill for clinical services they provide in some circumstances. The services must medically necessary and within a pharmacist’s scope of practice (or allowed through a statewide protocol) or a within collaborative practice agreement (CPA). Additionally, there are state-specific and plan rules and requirements that may apply.

These clinical services are different from those typically billed through our Pharmacy Benefit Manager (PBM). If you’d like more information about enrolling in the Express Scripts network, visit the PBM page.

If you’d like more information about our Medication Therapy Management (MTM) network, visit the MTM page.

Some examples of plans for which pharmacists can bill for medically necessary services:

  • Kentucky Marketplace plans
  • West Virginia Marketplace plans
  • Ohio Medicaid and Ohio D-SNP (with opt-in Medicaid coverage)

To become a CareSource Provider, pharmacists must enter into a contract with CareSource.

(Note: The contracting process may take several months from start to finish.)

Instructions for obtaining a CareSource Provider Contract:

Visit https://www.CareSource.com. Hover over the “Providers” tab. A purple box appears on the right with a link to “Become a CareSource Provider!”. Select the plan and state for which you would like to become a provider.

Fill out the “New Health Partner Contract Form.”

Under the “General Information” tab, select “I am not in the CareSource network and would like to create a contract request” from the “How Can We Help You Today” dropdown.

Note: If your practice (or pharmacy) already has a contract, and you’d like to modify it or add an additional pharmacist, instead choose “I am a contracted CareSource Health Partner and would like to: add a provider, add a location, update demographic information.”

You will now see four tabs on the “New Health Partner Contract Form.” You must enter information on three different tabs – “General Information”, “Provider(s)”, and “Submission.” It is important to note that the information you enter on the “General Information” tab applies to the practice (or pharmacy) and not to the individual pharmacist, and the information you enter on the “Provider(s)” tab applies to the individual pharmacist.

While filling out information on the “Provider(s)” tab and you are asked to provide “Specialty”, be sure to select “Pharmacist” from the dropdown.

To complete the “New Health Partner Contract Form”, you will need to have an NPI Number and register for Credentialing.

  • An NPI (National Provider Identifier) is a 10-digit number that identifies an individual provider for billing purposes. Each pharmacist who provides services must obtain their own NPI number.
    Visit https://nppes.cms.hhs.gov/assets/How_to_apply_for_an_NPI_online.pdf for detailed instructions on how to obtain an NPI number.
  • Credentialing is the process of verifying qualifications for providing services to our members. CareSource partners with CAQH (Council for Affordable Quality Healthcare) for credentialing of our providers. CAQH uses an online platform known as ProView that can be accessed at https://www.caqh.org.

Note to Ohio pharmacists seeking a Medicaid contract with CareSource: you must first register with the Ohio Department of Medicaid (ODM) which will manage the credentialing process through the Provider Network Module: https://managedcare.medicaid.ohio.gov/managed-care/centralized-credentialing

If you have any questions about the process of contracting or credentialing, call CareSource’s Provider Services at 1-855-852-5558. Once you receive your Welcome Letter from CareSource with your CareSource ID number, you have completed the contracting and credentialing process.

Other Useful Information

Be sure to prepare and maintain documentation of services rendered. Documentation must support services provided and billing codes submitted. At a minimum, documentation should include reason for encounter, relevant history, examination findings, test results, clinical impressions, plan of care and progress. CareSource reserves the right to audit documentation.

If you don’t have billing software, CareSource partners with Availity to offer electronic claim submission and real-time transactions at no charge through the Availity Portal. You can use the Availity Portal Registration Guide to sign up.

If you have further questions or suggestions specific to pharmacist provider status, please send an email to: rphclinicalservices@caresource.com.