Member Information for Providers

member-info-providersEligibility Verification

A member’s eligibility in the District Cares Program could change at any time. Please call the Customer Services Department at 866-930-0035 to verify enrollment and eligibility of members in program prior to rendering service. Providers may also use our Auto Eligibility Verification System to check a member’s eligibility 24 hours a day, 7 days a week.

Membership Card

Members are issued a District Cares Program membership card at the time of enrollment. Members are asked to present their membership card and identification to the provider when receiving medical services.

Copayment

Members are advised that copayments are due at the time of service. It is the provider’s responsibility to collect the appropriate copayment at the time of service.

Contacting New Members

Physicians are encouraged to contact new members. An active membership list is sent to all Primary Care Physicians monthly. By contacting the new member, the physician can introduce the patient to the educational process of the program’s benefits and member responsibilities. It can also promote the importance of establishing a medical record.

Change of Primary Care Physician

A District Cares Program member may change his or her Primary Care Physician at any time up to two (2) times in any 12-month period. The changes are completed by the Customer Service staff and the member’s name will appear on the new Primary Care Physician’s membership list for the next month.

Member Financial Responsibility

Members will bear full financial responsibility for payment of all charges for services for the following:

  • Non covered services
  • Covered services provided by a non-participating provider or facility
  • Services provided beyond the member’s benefit maximum

Billing for Non-Covered Services

Provider shall not, either directly or indirectly, bill, charge, or seek compensation from Members for Covered Services rendered; provided, however, that nothing herein shall be construed to prohibit Provider from collecting or pursuing collection of Program authorized Copayments or charges for non-Covered Services or seeking payment from other Payors. Prior to providing non-Covered Services to a Member, Provider shall:

  1. Inform the Member that the services to be provided are not Covered Services;
  2. Inform the member that Program will not pay or be liable for such services;
  3. Inform the Member that if Provider is seeking compensation for such services, the Member shall be financially liable for such services;
  4. Provide to the Member, the form agreement on Addendum E (PDF 24.6KB) hereto and obtain such agreement, once fully executed, from the member.

In the event Provider does not fully comply with items (1) – (4), the Member shall not be liable to Provider for such non-Covered Services.

 

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