Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 4: Primary Care Providers


Primary care providers are the heart of a PCCM program. All eight case-study states emphasized the importance of establishing adequate networks of PCPs and of developing relationships with those providers. As one official noted, states must take providers seriously and know how to support and serve them in order to have a successful PCCM program.

The contract requirements and expectations of PCPs are similar across PCCM programs. Generally, the PCP is expected to

  • provide and/or arrange for the delivery of a certain set of services, defined by the state;
  • provide 24-hour, 7 day-a-week coverage through an arrangement that meets the state's requirements;
  • follow the state's authorization procedures when referring a patient to specialty care;
  • accept all enrollees who either choose or are assigned to his/her panel;
  • provide education to the PCCM member about how to seek care;
  • not disenroll a patient from the panel unless certain criteria are met; and
  • review utilization reports, if available, to ensure that his/her patients are receiving appropriate care.

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