Prior Authorization

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These services require both a referral from a Primary Care Provider or specialist and Prior Authorization from CareSource.

Prior Authorization may be requested by phone at 1-800-390-7102 or in writing from the CareSource Medical Management department. Faxes should be sent to 1-888-577-5507.  The following services require Prior Authorization from CareSource before the service is provided:

• All Inpatient Care
• All Abortions
• All Home Care Services
• Nursing Facility Services
• Inpatient Rehabilitative Services
• Organ Transplants
• Durable Medical Equipment over $750 billed charges
  • The $750 rule does not apply to the DME/other items (below)– these require prior authorization:
    • All powered or customized wheelchairs
    • Manual wheelchair rentals over 3 months
    • All miscellaneous codes (example E 1399)
• Cosmetic procedures and plastic surgery
• Non-Formulary Drug Requests
• Ambulance and ambulette transportation – except for emergent or facility-to-facility transfers
• Diagnostic Procedures
  • MRI's
  • PET scan
  • Gastrointestinal Tract Imaging (video capsule)
• Pain management/clinic
  • Spinal Injections and Blocks
• Rehabilitative services
  • Physical therapy over 18 visits per calendar year
  • Occupational therapy over 18 visits per calendar year
  • Speech therapy
• Food Supplements/nutritional supplements
• All services rendered by non participating Providers
  • Effective 10/08 outpatient obstetrical services rendered by non-participating Providers to pregnant Members do not require Prior Authorization.

• CareSource does not require Prior Authorization for unlisted procedure CPT codes; however, we require a clinical record be submitted with your claim to review the validity of the unlisted procedure CPT code. Claims submitted without clinical records for unlisted procedure CPT codes will be denied. Denials will be reconsidered through the appeal process with pertinent clinical records.

Authorizations are not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits (and other factors). Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.

Get Prior Authorization

Providers must get Prior Authorization from CareSource before rendering some services. For a list of services that require Prior Authorization, please see Prior Authorization Required.

Please submit Prior Authorization requests to the CareSource Medical Services Department:

• By phone – Call Provider Services at 1-800-390-7102 and press the option for Prior Authorization
• By fax – Fax Prior Authorization requests to 1-888-577-5507
• By mail – Send Prior Authorization requests to:

CareSource
Attn: Medical Services Department
P.O. Box 1307
Dayton, OH 45401-1307

Written Prior Authorization requests should be submitted on the Prior Authorization Request Form. Please provide all the information requested on the form.

Please adhere to these time frames when requesting Prior Authorization:

• Prior Authorization requests for routine services should be received three to five working days prior to the scheduled day of service.
• Requests for urgent services should be phoned or faxed as soon as the need is identified.
• Emergency services never require authorization. All follow-up care will be rendered by the PCP. Emergency services may be retrospectively reviewed to determine medical necessity. The use of the emergency department as a primary practice site is discouraged.
• Providers have 180 days from the date of service or 90 days from the EOP date denying the claim for requiring a Prior Authorization to submit a request for retrospective authorization.

All services that require Prior Authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services for which Prior Authorization is required but not obtained.

Referral to a specialist

CareSource uses a paperless referral system to make it easy for Primary Care Providers (PCPs) to refer their patients to participating specialists. To make a referral, PCPs simply:

• Document the referral in the member's medical chart. Please note the number of visits or length of time for each referral
• Tell the member how to get the service
• Notify the specialist of the referral

PCPs are not required to use a referral form or send a copy of it to CareSource. They also do not have to get Prior Authorization to make a referral to a participating specialist.

To receive a referral from a PCP, specialists simply document in the patient's medical chart that the patient was referred for services. Please note the number of visits or length of time for each referral. Referral numbers are not required on claims submitted for referred services.

Please remember that only PCPs can issue referrals to additional specialists. Generally, specialist-to-specialist referrals are not allowed. However, in some cases, specialists may provide services or make referrals in the same manner as a PCP.

For more information about which services require a referral, please see Provider Manual.