Claims Submission

Submit a claim

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
  • 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
  • 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

To find out how to submit paper claims, please see Paper Claims.

To find out how to submit electronic claims, please see Electronic Claims.

To find out how to code your claims, please see Code Sets.

To find the deadlines for filing your claims, please see Filing Timeframes.

Explanations of Payment (EOP)s are statements of the current status of your claims. For more information, please see Claims Payment. 

As a Medicaid managed care plan, CareSource is always the payer of last resort if the member has other health insurance or was involved in an accident. For more information, please see Coordination of Benefits.

For more information, please call the Provider Services at 1-800-390-7102 or see the Provider Manual.
Please note: Non contracted providers are paid at Michigan Medicaid Fee-for-Service rates.

Paper claims

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.

Information needed

All paper claims must include the following information:

  • 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

(Please note: your claims may process faster if the CareSource provider number is included.)

Please use your CareSource provider billing number on all claims. If you are unsure of your provider billing number, please contact Provider Services at 1-800-390-7102.

Please send all paper claim forms to:

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

For more information, please see the Provider Manual.

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:

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

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.

Filing timeframes

Submission

Participating providers may submit claims to CareSource up to 365 days after the date of service.

Returns

Claims may be returned to the provider if:

  • They contain incomplete, incorrect or unclear information
  • The provider or facility information does not correspond to the information in CareSource's claim processing system
  • There is no W-9 on file

If this happens, providers have 90 days from the date they are informed of the unpaid claim to submit the information needed for processing the claim.

All third-party zero-balance claims and Explanations of Payments (EOP) must be submitted to CareSource within 90 days of the date on the third-party claim or EOP.

Appeals

If CareSource denies a claim, providers have 90 days from the date they are informed of the unpaid claim to appeal it. For more information, please click on File an Appeal.

If you use a billing service or an Electronic Data Interchange (EDI) clearinghouse to submit electronic claims, please confirm with them the dates that claims are submitted to and received by CareSource. Submission to and acceptance by your billing vendor does not guarantee that claims have been forwarded to and received by CareSource within the 365-day timely filing guidelines.

CareSource has established claim submission timeframes to maintain the quality and integrity of our health plan and our valued partnership with you. We appreciate your adherence to these timeframes which, in turn, will help ensure your timely reimbursement.

For more information, please see the Provider Manual.

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

At CareSource, it is our practice to employ the latest in proven computer technology to process your claims accurately and efficiently. To this end, 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. We believe that clinical editing software helps ensure that your claims are processed consistently, accurately and efficiently.

For more information, please see the Provider Manual.