Claims Submission

CareSource accepts claims in a variety of formats, including 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

Electronic Claims Submission

  • CareSource has invested in an EDI system to enhance our service to participating providers. Our EDI system complies with HIPAA standards for electronic claims forms. We are committed to offering you the most flexible and efficient means possible of doing business with us.

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
  • Claims that have an Explanation of Benefits from another insurance carrier 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

As a Medicaid managed care plan, CareSource is always the payer of last resort if the member has other health insurance. For more information, please see our Coordination of Benefits policy.

Please note: Non-contracted providers are paid at Michigan Medicaid Fee-for-Service rates.

Claim Forms

CareSource accepts paper 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, formerly UB92 form (for hospitals)

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

Claims Must Include:

  • Patient (member) name
  • Member's CareSource ID number
  • Member's date of birth
  • Member's complete address
  • Place of service - Please use current CMS (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
  • Prior Authorization number, where applicable
  • Provider NPI number
  • Federal tax ID number
  • Billed charges for each line
  • Total billed charges
  • Other insurance information
  • Provider billing number - If you have multiple provider billing numbers, please include the number that corresponds to the organization and location from which you provided the service
  • Signature of provider or supplier

  • We recommend you include your CareSource Provider Billing Number on all claims. If you are unsure of you Provider Billing Number, please call Provider Services at 1-800-390-7102.

Please send all paper claim forms to:

CareSource
P.O. Box 1307
Dayton, OH 45401-1307

Code sets

The Health Insurance Portability and Accountability Act (HIPAA) requires that the health care industry use certain code sets when submitting electronic claims. To simplify the process of claims submission, CareSource has extended the HIPAA requirements to paper claims as well.

Please use the following code sets when submitting paper or electronic claims:

Unlisted, Unclassified CPT/HCPCS Codes and Claims

If a procedure cannot be classified by a CPT or HCPCS code, please include the following information, as applicable, with the claim form:

  • A full, detailed description of the service provided
  • A report, such as an operative report or a plan of treatment
  • Any information that would assist in determining the service rendered

Helpful Resource for Reducing Denied Claims

The National Correct Coding Initiatives (NCCI), developed by CMS, is a helpful resource for providers to check procedure-to-procedure codes in an effort to bill CareSource correctly for claims.

This website also includes in-depth instruction on how to appropriately bill modifiers (a common error), to overall reduce claim denials and appeals. For additional questions, please talk with your Professional Relations Representative.

This information is also needed if a procedure is assigned an unlisted CPT/HCPCS code. For example, 84999 is an unlisted lab code that would require additional explanation.

Appeals

If CareSource denies a claim, providers have 365 days from the date of service to appeal it. For more information, please see our Appeals and Grievances section.

EPSDT codes

When submitting claims for EPSDT exams, please use the following age-specific CPT codes:

  • New Patient/Initial Exam CPT Code Description 99381
  • Infant (age under 1 year) 99382
  • Early childhood (age 1-4 years) 99383
  • Late childhood (age 5-11 years) 99384
  • Adolescent (age 12-17 years) 99385
  • Age 18-20 years
  • Established Patient/Periodic Exam CPT Code Description 99391
  • Infant (age under 1 year) 99392
  • Early childhood (age 1-4 years) 99393
  • Late childhood (age 5-11 years) 99394
  • Adolescent (age 12-17 years) 99395
  • Age 18-20 years

Clinical Editing

CareSource uses clinical editing software to help evaluate the accuracy of diagnosis and procedure codes on submitted claims.

CareSource's clinical editing software finds any coding conflict or inconsistent information on claims. For example, a claim may contain a conflict between the patient's age or sex and diagnosis, such as a pregnancy diagnosis for a male patient. Our software resolves these conflicts or indicates a need to seek additional information from the health care provider.

Please remember that CareSource's clinical editing software helps evaluate the accuracy of the procedure code only, not the medical necessity of the procedure.

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)