Check Eligibility

We recommend that you check member eligibility each and every time a member presents for services, as member eligibility can fluctuate. Changes in health status such as pregnancy or certain medical conditions may also cause changes in plan eligibility.

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

Member ID Card

The member ID card is used to identify a member; it does not guarantee eligibility or benefits coverage. Members may disenroll from CareSource and retain their previous ID card. Members may lose Medicaid eligibility at any time.

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, mental health 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.

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.

Prenatal Services and Newborn Enrollment 

Encourage CareSource members to see you as recommended for prenatal care! Your patients can enroll in the Babies First program by completing the Babies First online enrollment form.

Newborns whose mothers are members of our health plan are covered from the date of birth. In most cases, the newborn’s name will appear on the primary care provider’s member eligibility list for the month following the birth.

Please contact Provider Services to verify eligibility.

Please note that the mother must contact her county caseworker as soon as possible to establish eligibility for her baby.