General Plan Information

Your Responsibilities 

Be Enrolled and Pay Required Premiums

  • Benefits are available to you only if you are enrolled for coverage under the plan. To be enrolled under the plan and receive benefits, your enrollment must be in accordance with the plan’s and the Health Insurance Marketplace’s eligibility requirements, as applicable. You must also qualify as a covered person. You must also pay any premiums required by the Marketplace and/or the plan.

Recoupment of Overpayments

  • If you received an invoice from CareSource with a credit balance shown, this represents money owed to you. We can apply the balance toward future premium amounts or refund the money to you at your request. If you choose to receive a refund, please contact Member Services at 1-833-230-2099 (TTY: 711) Monday through Friday, 7 a.m. to 7 p.m. Eastern Time. If you request a premium refund, it will be sent to you within 30 days. If your coverage has been terminated, any refunds of premiums that may be due will be generated and sent to you within 90 days.

Choose Your Health Care Provider

  • It is your responsibility to select the network providers and network pharmacies that will provide your health care. We can help you find network providers and network pharmacies. Use the Quick Links Menu to access our Find a Doctor tool and our Find a Pharmacy tool.

Your Financial Responsibility

  • You must pay copayments, coinsurance and the annual deductible for most covered services.
  • You must pay the cost of all health care services and items that exceed the limitations on payment of benefits or are not covered services.

Show Your ID Card

  • To make sure you receive your full benefit under the plan, you should show your ID card every time you request health care services. If you do not show your ID card, your provider may fail to bill us for the health care services delivered. Any resulting delay may mean that you will not receive benefits under the plan to which you would otherwise be entitled.

Federally Recognized Tribes

  • If you are a member of a federally recognized tribe and your household income is at or below 300% of the federal poverty level and you enrolled in a zero-cost plan, you will have no cost sharing (including copayments, coinsurance, and deductibles) for covered services. More information, including a list of federally recognized tribes, is available online at:
  • Regardless of your household income, there is no cost sharing if you receive services from an Indian health care provider or through referral under the Contract Health Services program administered by the Indian Health Service.

Our Policies

Explanation of Benefits

After you receive health care services, you will receive a written Explanation of Benefits (EOB) summarizing the benefits you received. This EOB is not a bill for health care services. The EOB shows you what services were billed to CareSource and how they were paid. It lists:

  • The member who got the service
  • The provider who billed for the service
  • The date the service was received
  • A description of the service
  • The amount CareSource paid for the service
  • How much you owe or already paid for the service, if anything

If you do owe for a service, you will get a bill from the provider. We encourage you to save these EOB statements and pay only the amount listed as your responsibility. If you get a bill from a provider for more than the amount the EOB shows as your responsibility, or that shows incorrect information, please call Member Services at 1-833-230-2099 (TTY: 711).

Premium Payment Grace Period

A grace period is a short period of time after your monthly health insurance payment is due, and payment has not been received.

Grace Period

After you pay your initial payment (also called a Binder Payment) and start your coverage, you are eligible for a grace period for the payment of premiums. The grace period begins when your premium is not paid in full by the due date. This impacts how the Plan processes and pays your claims during this period. The grace period terms vary based on whether you receive an Advance Premium Tax Credit (APTC).

If you receive APTC: your grace period will be the three (3) consecutive months following your missed premium payment. During this time, we shall:

  1. Continue to pay for covered services during the first month of the grace period.
  2. Hold processing covered services provided during the second and third months of the grace period or reserve the right to recover any amounts we may pay during this period.
  3. Reject prescription drug services during the second and third months of the grace period.
  4. Notify network providers of the possibility for denied claims during the second and third months of the grace period.

If you are not receiving APTC when you enter the grace period, your grace period will be thirty-one (31) consecutive calendar days following the due date of your unpaid premium.

During this time, we shall:

  1. Hold processing of claims for covered services provided during the grace period or reserve the right to recover any amounts we may pay during this period.
  2. Reject prescription drug services requested during the grace period.
  3. Notify network providers of the possibility for denied claims during the grace period.

There are two ways for the grace period to come to an end:

  1. Pay the premium amount due in full before the grace period expires. When this happens:
    • We will process all claims that were held.
    • We will notify network providers that you are no longer in the grace period.
    • We recommend that you contact your Pharmacy to have your Prescription Drug claims reprocessed.
  2. The grace period passes without payment in full. When this happens:
    • We will terminate your coverage back to the end of the first month of the grace period if you are receiving APTC; and to the end of the last month paid for those not receiving APTC.
    • We will deny any claims held during the grace period.
    • We will notify network providers and the United States Department of Health and Human Services, when appropriate, that you are no longer in the grace period.
    • See your Evidence of Coverage, When Coverage Ends, for further details.

If you have not made your initial payment and effectuated your coverage, then the grace period provisions above do not apply to you. You are responsible for the costs of all health care services you received when the policy is not effectuated.

Prescription Drug Formulary

Your plan uses a list of covered drugs, called the Marketplace Drug Formulary. Your cost share and limitations of coverage are represented on this list. Drugs not included on this list are not covered. In the event you need an exception to cover a drug not listed on the Formulary, you may call Member Services at 1-833-230-2099 (TTY: 711) to make the request, or complete the online Member Exception Request for Non-Formulary Medication to begin the request for an Internal Exception Review.

CareSource then contacts your prescribing provider. We may ask your provider to give us written clinical documentation about why you need an exception. Health care providers must provide this information.

For a standard exception review of medical requests, the timeframe for review is 72 hours from when we receive the request. For expedited exception review requests, the timeframe for review is 24 hours from when we receive the request.

If CareSource denies the drug exception, you have the right to request an external review. If you feel we have denied the non-formulary drug exception request incorrectly, you or your Authorized Representative may send a written request for an External Review. We must follow the External Reviewer’s decision.

An Independent Review may be requested by you, your representative, or your prescribing provider by mailing or calling:

North Carolina Department of Insurance
Smart NC
325 N. Salisbury Street
Raleigh, NC 27603
Phone: 1-855-408-1212
Fax: 919-807-6865

To request an expedited review for urgent circumstances, select the “Request for Expedited Review” option in the External Review Request Form.

Out-of-Network Liability and Balance Billing (No Surprises)

Health care services you receive from non-network providers are not covered services unless:

  • A non-network provider renders emergency health services to you.
  • You receive emergency or urgent care while you are temporarily outside the service area.
  • There is a specific situation involving the continuity of your health care.
  • You receive health care services from a non-network provider (such as an anesthesiologist or radiologist) while you are in a hospital or other facility that is a network provider, or
  • The health care services you need are covered services under the Plan and not available from a network provider or Facility. In this case, you, your PCP or other network provider must obtain our prior authorization.

If you receive emergency care from a non-network provider you will not be responsible for cost share amounts (deductible, coinsurance, and copayments) more than what they would have been if you received care from a Network provider.

For non-emergency care received out of network, in addition to applicable in-network cost shares (deductible, coinsurance, and copayments), you may be required to pay the excess of the amount of the out-of-network provider charges over the amount that CareSource is required to pay. This is called balance billing.

An out-of-network provider may balance bill you for non-covered services.

In some situations as required by law, a non-network provider is not allowed to bill you for services covered by CareSource, when they are aware CareSource is a Health Maintenance Organization. Please refer to your Evidence Of Coverage for more details.

Network providers are not allowed to balance bill you for covered services. You are only responsible for the cost shares outlined by your plan.

If you are being balance-billed for covered services by a Network provider, please contact Member Services at 1-833-230-2099 (TTY: 711).

Medical Necessity

Medical necessity is defined as covered services and supplies that are (1) Provided for the diagnosis, treatment, cure or relief of a health condition, illness, injury or disease; except as allowed under G.S. 58-3-255, not for experimental, investigational, or cosmetic purposes. (2) Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms. (3) Within generally accepted standards of medical care in the community. (4) Not solely for the convenience of the insured, the insured’s family, or the provider. 

For medically necessary services, nothing in this section prevents CareSource from comparing the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered.

Prior Authorization Timeframes and Services that Require a Prior Authorization

We must approve some services before you obtain them. This is called prior authorization or preservice review. For example, any kind of inpatient hospital care, except maternity care, requires prior authorization. If you need a service that we must first approve, your in-network doctor will call us for the authorization. If your in-network doctor does not call to get authorization, you will only have to pay for the charges you would have been responsible for if your care was medically necessary and we approved it. If you do not use an in-network provider and do not get prior authorization, you may have to pay up to the full amount of the charges. Please refer to your ID card and Plan Documents for specific coverage information after you enroll.

We will make our benefit decisions within the timeframes set forth in your Evidence of Coverage (EOC). You can find your EOC in your annual member material packet, or online under Plans/Plan Documents.

Standard Authorizations are reviewed, and notice provided within 3 business days of request. Urgent requests are reviewed, and notice provided within 24 hours of request.

CareSource keeps track of the services you get from health care providers. We discuss some services with your providers before you get them. We do this to make sure the services are appropriate and necessary.

Your doctor will work with us to get a prior authorization for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization. Although your provider should get a prior authorization from us, you may want to ensure that your provider has received our approved prior authorization.

Many other services do not need a prior authorization. You do not need one to see your PCP or most specialists. Your doctor will tell you when you need these types of care.

Your Evidence of Coverage includes a detailed list of covered services and requirements. Check this document if you have questions about a specific service.

Download our Prior Authorization List:

Claims Policies

Your provider is responsible for requesting payment from us. If your provider is unable to submit claims, you may submit a claim directly to us using the member claim form or by calling Member Services at 1-833-230-2099 (TTY: 711).

Written notice of claim must be given to us within 180 days from the date services were rendered, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the member to CareSource or to any authorized agent of CareSource, with information sufficient to identify the member, shall be deemed notice to us.

Submit claims to: CareSource, P.O. Box 8730, Dayton, OH 45401-8730

See your EOC or call Member Services for more information about claims policies for your plan.

Retroactive Denials

A retroactive denial is the reversal of a previously paid claim. That is, we deny a claim after we have paid it, and take the money back from the provider.  If a claim is retroactively denied, then you, the member, may become responsible for payment.

Claims may be denied retroactively, even after you obtained services from a provider, based on retroactive changes to eligibility. These include but are not limited to failure to pay premiums and instructions from the Marketplace.

The best way to avoid retroactive denials:

  • Make your premium payments on time and in full
  • Talk to your provider about whether any service they perform is a covered benefit
  • Whenever possible, get services and prescriptions from in-network providers and pharmacies