Primary Care Provider Roles & Responsibility

All CareSource members choose or are assigned to a primary care provider (PCP) upon enrollment in the plan. Members have the option to change to another participating PCP as often as needed. Members initiate the change by calling our Member Services department at 1-800-488-0134.

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.

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 care management care treatment plans and notifying CareSource of members who may benefit from care management.

In addition, 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

PCPs 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 patient calls 24 hours a day, 7 days a week.
  • Following all referral and prior authorization policies and procedures as outlined in this 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.