Appeals and Grievances

Claims Appeals

CareSource is making it easier to work with us by extending timely filing requirements from 90 to 365 days from the date of service for Michigan Providers. This new policy is effective September 1, 2010.

Claims payment appeals should include:

  • Member's name and identifying information
  • Claim number
  • The service for which payment was denied
  • Date(s) of service
  • The reason CareSource's decision to deny payment should be reconsidered
  • Any clinical notes or other medical information to support your request

When submitting an appeal for a claim dispute it's important to send the clinical notes. In order to conduct a thorough review, CareSource needs all the pertinent clinical information to make the appropriate determination of the claim.

We will notify you of a decision within 30 days, and any needed adjustments will be made to a future payment.

Please complete a Claims Appeals Form and send it to:

CareSource
Attn: Provider Appeals
P.O. Box 2008
Dayton, OH 45401-2008

For more information, please see the Provider Manual.

For more information on Timely Filing please see the FAQs.

Clinical Appeals

We want Providers to be happy with CareSource. However, if you disagree with a clinical decision we have made, we make it easy for you to be heard.

Timeline for Clinical Appeals

Clinical appeals can be submitted by the member or provider after receiving a letter from CareSource denying coverage. Appeals can be filed by a:

  • Provider - within 180 days of receipt
  • Provider on behalf of a member with written authorization from the member - 90 days of receipt
  • Member - within 90 days of receipt

CareSource may request additional information from the provider to document clinical information that pertains to the appeal to assist CareSource in rendering the decision.

To Submit a Clinical Appeal

Providers may send a letter requesting the appeal with the following information:

  • The member's name, CareSource member ID number, date of birth
  • The provider's name and CareSource provider billing number
  • The type of service for which CareSource denied coverage, and the date and place when it was to be provided
  • The reason CareSource's decision to deny coverage should be reconsidered
  • Any additional medical information to support your request

Please Submit Clinical Appeals to:

CareSource
Attn: Clinical Appeals
P.O. Box 2008
Dayton, OH 45401-2008

All clinical appeals and clinical information are reviewed by clinicians previously uninvolved with the case.

  • Member Clinical Appeals: Members will be notified of CareSource's decision within 15 calendar days.
  • Provider Clinical Appeals: Providers will be notified of CareSource's decision within 30 calendar days.

Expedited Medical Appeals

A provider may ask CareSource to expedite a clinical appeal if:

  • The provider or member believes that the time required for a standard appeal resolution could seriously jeopardize the member's life, health or ability to attain, maintain or regain maximum function.

To Expedite:

Call: 1-800-390-7102

  • CareSource will decide whether to expedite the appeal within 24 hours
  • CareSource will verbally notify the member of the resolution within 72 hours
  • CareSource will also send written notification to both member and provider on the same business day of the decision

Denied Expedited Appeals

If CareSource decides not to expedite the clinical appeal, we will notify the member and provider of that decision in writing within 72 hours. CareSource will then follow the process and timeframes for standard medical necessity appeals.

CareSource will not penalize any member or provider in any way for appealing a clinical decision, or for asking us to expedite a clinical appeal.

Extension Requests

Members may verbally request that CareSource extend the timeframe to resolve any medical necessity appeal request up to 14 days. CareSource may also request an extension. CareSource must submit documentation that the extension is in the member's best interest to the Michigan Department of Community Health (MDCH).

If MDCH approves the extension, CareSource will notify the member in writing of the extension reason and new timeframe.

Provider Grievances

We hope that you are happy with CareSource. However, there may be times you disagree with our quality, professional competency or conduct. If you would like to file a grievance for issues that are contractual or non-clinical, please send it to:

CareSource
Attn: Provider Relations
P.O. Box 8738
Dayton, OH 45401-8738