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 certain medical conditions may also cause changes in plan eligibility and coverage status.
| Important Tools & Resources | |
|---|---|
| Provider Portal | Member ID Card |
You can always verify member eligibility by accessing the Provider Portal or through an eligible Electronic Data Interchange (EDI) clearinghouse. | The CGHC ID card displays member copays for office visits on the front of the card in the designated area. The suffix at the end of the ID card must be included when billing for services to avoid claim rejection. |
Please note: CGHC applies a federally mandated 3 month grace period to members who have advance premium tax credit (APTC). Members who do not have APTC receive a 1 month grace period. If a member becomes delinquent in premium payments, we will identify this on the provider portal.
- For members receiving an APTC, 1 month after the start of a members grace period, we will suspend the member’s pharmacy benefits and pend medical claims for services rendered.
- For non-APTC members, starting day 1 of their grace period, CGHC will suspend the member’s pharmacy benefits and pend medical claims for services rendered during the members grace period.
- If members bring their account into good standing before the expiration of their grace period, pharmacy benefits will start again and pended claims will be processed. 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 and CGHC 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 (Coming Soon) – This form can be used to designate a person to speak on the member’s behalf.
Please encourage CGHC members to complete the Member Consent/HIPAA Authorization Form so all providers involved in their care can effectively communicate and coordinate their care.
For questions not addressed on our website, please call Provider Services at 1-877-514-2442. You can reach us Monday through Friday from 8 a.m. to 5 p.m. Central Time (CT).