Check Eligibility
We recommend that you check member eligibility every time a member presents for services, as member eligibility can fluctuate. Changes in health status such as certain medical conditions may also cause changes in plan eligibility and coverage status.
| Important Tools & Resources | |
|---|---|
| Provider Portal | Member ID Card |
Verify member eligibility any time by accessing the Provider Portal or through an eligible Electronic Data Interchange (EDI) clearinghouse. | The CareSource ID card displays member copays for office visits on the front of the card. The person code suffix must be included at the end of the ID number when billing for services to avoid claim rejection. |
Grace Period notes: Members who do not have APTC receive a 1-month grace period. If a member’s account becomes delinquent in premium payments, we will identify this on the provider portal.
- APTC – CareSource applies a federally mandated 3-month grace period to members who have an advance premium tax credit (APTC). One month after the start of a member’s grace period, we will suspend their pharmacy benefits and pend medical claims for services rendered.
- No APTC – Members who do not have an APTC receive a 1-month grace period. Starting on the first day of their grace period, we will suspend their pharmacy benefits and pend medical claims for services rendered during the member’s grace period.
- Return to good standing – If the member brings their account into good standing before their grace period expires, pharmacy benefits will start again and pended claims will be processed.
- Expiration of Grace Period – If the member does not bring their account current by the expiration of the grace period, the member is terminated due to nonpayment of premium. If this happens, we will deny all pended claims for no coverage.
Quick Tips: Member Consent
- Sensitive health information (SHI) – When you check eligibility on the provider portal, you can also determine if a member has granted consent to share SHI.
- Sensitive health diagnosis – 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 member has granted consent to share SHI. On the provider portal, a message displays on the page if the member has not consented to sharing SHI.
- Member Consent/HIPAA Authorization Form – This form can be used to designate a person to speak on the member’s behalf. Please encourage CareSource members to complete form so all providers involved in their care can effectively communicate and coordinate care.
For questions not addressed on our website, please call Provider Services at 1-833-230-2101. You can reach us Monday through Friday from 8 a.m. to 6 p.m. Eastern Time (ET).