Primary care

A PCP is a specific clinician responsible for coordinating the health care needs of certain members. Providers with the following specialties can be designated as PCPs: general practice, family practice, internal medicine, pediatrics, OB/GYN, physician assistants, certified nurse midwives and advanced practice nurses (nurse practitioners). 

When members enroll in any of our programs, they choose a PCP or are assigned one. PCPs agree to accept member assignment and are the principle point of contact for our members in coordinating and managing their care.

Primary care provider roles and responsibilities

The PCP’s role is to provide members with a medical home, the member’s first stop in the health care process and a centralized hub for a wide variety of ongoing health care needs. UniCare Health Plan of West Virginia, Inc. (UniCare) furnishes each PCP with a current list of enrolled members assigned to that PCP. 

The PCP’s role is to:

• Coordinate members’ health care 24 hours a day, 7 days a week.
• Develop members’ care and treatment plans, including preventive care.
• Maintain members’ current medical records, including documentation of all services provided by the PCP and any specialty or referral services.
• Adhere to wait times, as outlined within the provider contract and the provider manual.
• Referrals for specialty care and other medically necessary covered services, both in-network and out-of-network, consistent with UniCare's utilization management policies.
• Coordinate with outpatient clinical services.
• Provide complete information about proposed treatments and prognosis for recovery to our members or their representatives.
• Facilitate interpreter services by presenting information in a language that our members or their representatives can understand.
• Ensure that members’ medical and personal information is kept confidential, as required by state and federal laws.
• Obtain signed consent before providing care.
• Adhere to UniCare and West Virginia Medicaid managed care program policies.
• Facilitate adherence to the EPSDT periodicity schedule.

The PCP’s scope of responsibilities includes providing or arranging for:

• Routine and preventive health care services.
• Emergency care services.
• Behavioral health services.
• Hospital services.
• Ancillary services.
• Interpreter services.
• Referrals for specialty services.
• Coordination with outpatient clinical services, such as therapeutic, rehabilitative or palliative services.

How to verify a UniCare member has designated you as their PCP

UniCare keeps providers up-to-date with detailed member information. We also furnish each PCP with a current list of assigned members and provide medical information about the members’ potential health care needs. Providers may use this information to provide care and coordinate services more effectively.

PCPs should provide services only to those UniCare members who have chosen you as their PCP. Verify that a member is assigned to you by using the following methods:

• Go to https://www.availity.com* and select Login to enter the secure provider portal. Then, log in to the provider online reporting tool to view the monthly PCP rosters.
• Call UniCare’s interactive voice response (IVR) system at 1-800-782-0095. The IVR system is available 24 hours a day, 7 days a week. When asked to enter your provider identification, use either your billing NPI number or your TIN. 
• Call the Customer Care Center at 1-800-782-0095:
  • Speak to a Customer Service representative
  • Customer Care Center hours are Monday through Friday, 8 a.m. to 6 p.m.

* Availity, LLC is an independent company providing administrative support services on behalf of UniCare Health Plan of West Virginia, Inc.

PCP referrals

PCPs coordinate and make referrals to specialists, ancillary providers and community services. Providers should refer members to network facilities and providers. When network facilities and providers are not available, providers should follow the appropriate process for requesting out-of-network referrals. 

Please note: Specialty referrals to in-network providers do not require prior authorization.

For a full list of guidelines for primary care provider referrals, please refer to the Provider Manual .