Checking a Member’s eligibility for services and the available benefits is a crucial step in beginning to provide clinical services to Members. This step will ensure that you do not provide services for a benefit that is not covered (excluded benefit), or provide a service that is not covered for that Member.

In the secure Transactions section of Provider Express, you can search for a Member’s benefits and eligibility. Once you log on to the secure Transactions, you will need either the Member’s ID, Name and Date of Birth, or access to your Patient List (a feature you can customize yourself.)

Finding Member eligibility and benefit information is easy. Once you access the Member’s record, the eligibility information will display. Demographic information for the Member is available, and benefits information will display when you click on the Member name.

The benefit information page displays eligibility information as well as year-to-date accumulators for both deductible and out-of pocket expenses (if applicable) and benefit details.

The Member’s benefits information will indicate whether or not the service you are planning to provide requires authorization. If authorization is required, you may request that authorization online (This short video shows you how). If you are not able to authorize the service online, you must call the number on the back of the Member’s card for authorization.

For full details on how to access member benefits and eligibility, please view this brief video.