We recommend that you check member eligibility each and every time a member presents for services, as member eligibility can fluctuate.
You can always verify member eligibility by accessing the Provider Portal or through an eligible Electronic Data Interchange (EDI) clearinghouse.
Please note: CareSource Marketplace members may be eligible for a 31- or 90-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 cost-shares for key services as well as their deductible and maximum out of pocket (MOOP) limits on the front of the card in the purple box. The member suffix associated to the member being treated as listed on the ID card must be included when billing for services to avoid claim rejection.
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.
Please encourage CareSource members who have not consented to complete the 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.