Check Eligibility

We recommend that you check member eligibility each and every time a member presents for services, as member eligibility can fluctuate.

You can easily verify member eligibility by accessing the Provider Portal or through an eligible Electronic Data Interchange (EDI) clearinghouse.

Please note: CareSource applies the 90-day grace period to members who have APTC. Members who do not have APTC will have a 30-day grace period. If a member becomes delinquent in premium payments we will identify this on the Provider Portal. At the end of the first month of the grace period, we will suspend the member’s pharmacy benefits, but continue to pay for medical claims. At the end of the grace period, if the member is terminated due to non-payment of premium, CareSource will recoup any payments made for claims received in the second and third months of the grace period.

The CareSource ID card displays member copays for office visits on the front of the card in the purple box. The suffix at the end of the ID card must be included when billing for services to avoid claim rejection.

Member ID Card

The CareSource ID card displays member copays for office visits, Emergency Department (ED), and Urgent Care, as well as Deductible and Member Out-Of_Pocket (MOOP) limit details on the front of the card. Please ensure to use the appropriate member suffix when billing to avoid claim rejection. Dependent Member suffixes can be fond in front of their name on the ID card and should replace the Member ID’s “-00” suffix.

A detailed view and explanation of the member ID card is available in the Member ID Card Flier.

Member Consent

When you check eligibility on the Provider Portal, you can also determine if a member has granted consent to share sensitive health information (SHI). SHI is a subset of protected health information (PHI) which may require consent from the individual in order to be shared with others.

When a member has a sensitive health diagnosis (e.g., treatment for drug/alcohol use, genetic testing, HIV/AIDS, or sexually transmitted diseases), you should verify if the patient has granted consent to share health information. On the Provider Portal, a message displays on the Member Eligibility page if the member has not consented to sharing sensitive health information (SHI).

Please encourage CareSource members who have not consented to complete the Navigate Member Consent/HIPAA Authorization Form so that all providers involved in their care can effectively coordinate their care. This form is located on the member Forms page.

The Member Consent/HIPAA Authorization Form can also be used to designate a person to speak on the member’s behalf. This designated representative can be a relative, a friend, a physician, an attorney or some other person that the member specifies.