Frequently Asked Questions

General questions

Billing

Claims

Appeals

Benefits

General Questions

What is CareSource?

CareSource is a non-profit Medicaid managed care organization that serves Michigan Medicaid consumers. Our focus is on prevention and partnering with local health care Providers to offer the services our members need to remain healthy.

As a managed care organization, our goal is to improve the health of our members by using a defined network of participating health care providers. Primary Care Providers (PCPs) in the network coordinate patient care by referring members to specialists when needed or obtaining Prior Authorization from Caresource for certain services. See our Provider Directory.

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What are the advantages of participating with CareSource?

CareSource's foundation is our strong partnership with our contracted health care providers.

Because providers are so integral to the delivery of services, CareSource offers them a wide array of services and benefits, including:

  • Provider Service Center. Our knowledgeable and friendly representatives are available to answer your questions and address any concerns 8 a.m. to 5:30 p.m. Monday through Friday except holidays.
  • Enhanced reimbursement. CareSource offers enhanced reimbursement for its valued providers. We also offer a performance bonus to Primary Care Providers for providing certain well-child checkups and immunizations.
  • Electronic claims submission. CareSource accepts a variety of electronic claims formats.
  • Case management. Nurses are available to assist your patients in coordinating medical care and support services for a variety of conditions.
  • CareSource 24-hour nurse triage. Our registered nurses can answer health and medical questions and direct your patients to the most appropriate place for care 24 hours a day, 7 days a week.
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How can I become a participating provider?

If you are interested in becoming a participating provider with CareSource, please call our Provider Services at 1-800-390-7102 and ask to speak with the Provider Relations representative for your area.

We can give you the information and materials you will need to start the application process.  For more information, please see Provider Relations.

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How can I reach CareSource?

Call Provider Services at 1-800-390-7102.

Our friendly and knowledgeable representatives are available to speak with you 8 a.m. to 5:30 p.m., Monday through Friday, except holidays. The menu options will also let you speak with people from our medical management, pharmacy, appeals and Provider Relations departments.

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What services does CareSource cover?

CareSource covers all the same services as traditional fee-for-service Michigan Medicaid.

Members can get many services without a referral from their PCP. They can simply call for an appointment.

Members must get a referral from their PCP to receive some services. A few services require both a referral from your PCP and Prior Authorization from CareSource.

For more information, please see Covered Services.

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How do I make a referral?

CareSource uses a paperless referral system to make it easy for PCPs to refer their patients to participating CareSource 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 refer members to a participating specialist.

For more information, please see Make a Referral.

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What is a Primary Care Provider (PCP)?

The Primary Care Provider (PCP) is an integral part of CareSource. Through the PCP, CareSource delivers personalized, coordinated and systematic health care to its members.

PCPs provide:

  • Availability of a personal physician
  • Continuity of the member's total health care
  • Early detection and preventative health care services
  • Elimination of inappropriate and duplicate services

Among other things, the PCP is responsible for the EPSDT exam, including Lead Screening and Immunizations.

For more information, please see Primary Care Providers.

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How can my patients get services that CareSource does not cover?

CareSource does not cover some services, but members can still get them through Michigan Medicaid or another agency.

These services are:

  • Dental care - Call CareSource Member Services.
  • WIC services - Call your local health department
  • Services for people with developmental disabilities - Call your local community mental health agency
  • Drug and alcohol abuse services - Call your local substance abuse coordinating agency

For more information, please see Services Outside CareSource.

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Billing

Can I ever bill my CareSource patients?

State and federal regulations prohibit health care Providers from billing Medicaid consumers for services provided to them. CareSource monitors this activity based on reports of billing from members.

Please be aware that CareSource will cover all co-payments for its members. No member should be charged a co-payment for any type of service.

For more information, please see Member Billing Policy.

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How do I check member eligibility?

The CareSource ID card is used to identify members of our health plan; however, it does not verify eligibility for benefits since members may disenroll from CareSource and retain an old card. Therefore, it is important to verify member eligibility before providing services.

To verify member eligibility, please call CareSource's Provider Services at 1-800-390-7102 and press the options for member eligibility. You can also check Member eligibility on our secure online Provider Portal.

For more information, please see Check Member Eligibility.

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How do I obtain Prior Authorization?

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

Prior Authorization requests and notifications are submitted to the CareSource Medical Services Department:

  • By phone - Call our toll free number 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

For more information, please see Get Prior Authorization.

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Claims

How do I submit a claim?

CareSource accepts claims in a variety of formats, including paper and electronic claims.

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/UB04, formerly UB92 form (for hospitals)

Paper claim forms can be typed or computer generated. Please send all paper claims to:

CareSource
Attn: Claims Dept.
P.O. Box 1307
Dayton, OH 45401-1307

CareSource accepts electronic claims in the following file formats:

  • 837 ANSI ASC x 12N (004010A) for professional and claims. , including translation and communications software, enables computers to perform EDI transactions accurately and efficiently.

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

To submit claims electronically, providers must work with an electronic claims clearinghouse. CareSource currently accepts electronic claims through Emdeon , Netwerkes and Practice Insights.

For more information, please see Submit a Claim.

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Appeals

How do I file an appeal?

If you are dissatisfied with any medical necessity decision made by CareSource, we offer one level of appeal as mandated by MDCH.  Members have the right to a state hearing as a first or second level of appeal.

Please submit all appeal requests in writing to:

CareSource
Attn: Appeals
P.O. Box 1307
Dayton, OH 45401-1307

For urgent cases when a member's health may be affected if the appeal is not answered quickly, Providers may request an expedited appeal by phone by calling 1-800-390-7102. Providers must request an expedited appeal within 10 days from the date of the denial.

For more information, please see File an Appeal.

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Benefits

Does CareSource offer other benefits?

Yes! Besides covering all the same services as traditional fee-for-service Michigan Medicaid, CareSource also offers its members many other benefits and support services.

Some of our benefits and services for members include:

  • New Member Kits. These kits include a Member Handbook, Provider Directory, HIPAA Notice, and various health education materials.
  • Member Service Center. Members can call 1-800-390-7102 to speak with a representative 8 a.m. to 5:30 p.m. Monday through Friday, except holidays.
  • CareSource 24, our 24-hour nurse advice line. Members who have medical questions can call 1-866-206-0488 to speak with a registered nurse 24 hours a day, seven days a week.
  • Michigan Tobacco Quitline. CareSource offers free smoking cessation counseling to members through the Michigan Tobacco Quitline. CareSource also covers nicotine replacement therapy with Prior Authorization.
  • Transportation to medical appointments. Members can call for Transportation Services at 1-866-712-1057.
  • Case management. CareSource has nurse case managers who assist members with conditions like asthma, diabetes, congestive heart failure, obesity and high-risk pregnancy. Our goal is to help our members manage their condition through assessment, coordination of care, education and support.
  • Health information. CareSource members receive health information through a variety of vehicles including easy-to-read newsletters, brochures, and fliers.
  • Interpreter services. CareSource offers sign and language interpreters for members who are hearing impaired, visually impaired, do not speak English, or have limited English-speaking ability. These services are available at no cost to the member or provider.

For more information, please see Other Benefits.

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