Claim Submission

Submit a claim

CareSource accepts both paper and electronic claims. We encourage providers to submit routine claims electronically to take advantage of the following benefits:

  • Faster claims processing
  • Reduced administrative costs
  • Reduced probability of errors or missing information
  • Faster feedback on claims status
  • Minimal staff training or cost

Paper claim forms are required for services that need special processing, such as:

  • Procedures performed that do not have a corresponding (CPT) procedure code
  • Drug injections that don't have specific J code descriptions (J9999 and J3490)
  • Sterilization procedures – Consent forms must be attached
  • Services billed by report – Claims for services that include a modifier 22 and claims for unlisted procedures must be accompanied by an operative report plus any other documentation that will assist in determining reimbursement

Attention non-participating providers

Emergency Services – All in-patient services require prior authorization. Please call 1-800-488-0134 to obtain prior authorization for emergent admissions. Outpatient emergency services do not require prior authorization. Please submit claims electronically or for paper claims send to:


CareSource
Attn: Claims Dept.
P.O. Box 8730
Dayton, OH 45401-8730

Post Stabilization Services – Please call 1-800-488-0134 for post stabilization services if the member requires inpatient care for covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 to improve or resolve the member's condition. Such services shall be deemed prior authorized if CareSource does not respond within the one-hour timeframe for responding to a request for authorization being made by the emergency department.

Claim forms

CareSource accepts claims on the following forms:

  • CMS 1500, formerly HCFA 1500 form — AMA universal claim form also known as the National Standard Format (NSF)
  • CMS 1450 - UB-04, formerly UB92 form (for hospitals)
  • ADA Dental Form - for dental claims, use most current version

Paper claim forms can be typed or computer generated. Electronic claims must be submitted using HIPAA-compliant transaction and code sets.

Information needed

All claims must include the following information:

  • Patient (member) name.
  • Member's CareSource ID number.
  • Member's complete address.
  • Member's date of birth.
  • Other insurance information, if applicable.
  • Place of service. Please use current HCFA location codes.
  • ICD-9 diagnosis code(s).
  • HIPAA-compliant CPT or HCPCS code(s) and modifiers, where applicable.
  • Units, where applicable (Anesthesia claims require minutes).
  • Date of service for each service rendered.
  • Billed charges for each service line.
  • Total charge for claim.
  • Prior Authorization number, where applicable.
  • Federal tax ID number.
  • National Provider Identifier (NPI) number (required for electronic claims).
  • Provider's signature.
  • For prenatal or delivery services, the last menstrual period date is required on claims. Providers may estimate this date if necessary based on the gestational age of the child.

We recommend you include your CareSource Provider Billing Number on all claims. If you are unsure of you Provider Billing Number, please contact your CareSource Provider Relations Representative.

The CMS 1500 Claim Form Sample shows the information fields on a paper claim form.

Please send all paper claims to:

CareSource
Attn: Claims Department
P.O. Box 8730
Dayton, OH 45401-8730

Claim submission timeframes

Claims must be submitted within 180 days of the date of service. We will not be able to pay a claim if there is incomplete, incorrect or unclear information on the claim. If this happens, Providers have 90 days from the date the claim is denied to submit the information needed for processing the claim.

For more information please refer to the Claims Submission section of the Provider Manual.

National Provider Identification (NPI) number

To comply with the national mandate for NPI (National Provider Identifier), effective May 23, 2008, CareSource requires that your NPI number and Tax ID number be included on all electronic claims.

Claims that do not include your NPI and Tax ID will be rejected.

To help with this transition, we strongly encourage you to submit your CareSource provider ID on the claim, in addition to your required NPI and Tax ID numbers.

Please confirm these billing arrangements with all of your billing team and any claims clearinghouse.

The latest claim forms include a position for the NPI. Instructions for completing the following claim forms can be found online:

Apply for an NPI:

If you have not obtained your NPI, you can submit your application online (at no cost) through the National Plan and Provider Enumeration System at nppes.cms.hhs.gov – or by calling 1-800-465-3203 (TTY: 1-800-692-2326).