All Medicaid recipients receive eligibility from the state on a month to month basis. Because of this, CareSource cannot be provided member eligibility for the upcoming months.

Yes, a member's eligibility can be retro termed at any point during the month by the Michigan Department of Community Health (MDCH).

It is important to verify member eligibility before providing services. Patients must be eligible CareSource members at the time of service in order for services to be covered.

CareSource offers several ways to check member eligibility including by phone or here on our website.

Phone: 1-800-390-7102
Provider Portal: Available 24/7

For more information, please see How To Check Member Eligibility.

Yes! Any participating PCP may see eligible CareSource members. PCP's are responsible for verifying member eligibility before providing any services. Please log onto the Provider Portal to confirm member eligibility. Please note eligibility does not guarantee payment of the claim.

Appeals that have gone through the formal appeal process are deemed to be final.

Providers have 365 days from the date of service to notify CareSource. The 365 day timeframe should give ample time to cite references and documentation regarding the error.

Please see Appeals and Grievances for more information.

CareSource accepts claims in a variety of formats, including paper and electronic claims for up to 365 days from date of service or date of discharge.

Electronic claims:

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.

We recommend you include 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.

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)
• ADA J400 - ADA J400

Please send all paper claims to:

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

EDI claims are typically received and processed more quickly than paper claims. We require paper claim submission using the most current form version as designated by CMS, NUCC and the ADA. We cannot accept handwritten claims or SuperBills.

Tips for Submitting Paper Claims:

• Use only original claim forms. Do not submit claims that have been photocopied or faxed
• Fonts should be 10-14 point (capital letters preferred) with printing in black ink
• Do not use liquid correction fluid, stickers, labels or rubber stamps
• Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form
• Do not include handwritten information on the form
• We recommend including your 12 digit CareSource provider ID, which allows for fastest paper claim processing
• In general, using clean claim forms with legible print will allow for more efficient processing

The majority of clean claims are processed within 30 days; we strive to process all claims received within 90 days. Payment notification is made via EOP (Explanation of Payment).

Because of the large volume of claims that CareSource receives and processes, we ask for your cooperation in allowing at least 45 days from submission date before calling about a claim status or submitting a duplicate claim.

Claims status is one of many services available to our providers 24 hours a day through our secure Provider Portal. The pended claims report is another resource for claims status and it is sent bi-weekly.

State and federal regulations prohibit health care providers from billing CareSource members for services provided to them except under specific circumstances. Please remember that regulations state that health care providers must hold members harmless in the event that CareSource does not pay for a covered service performed by a provider unless CareSource denies prior authorization of the service. In this instance, the provider must notify the member in writing that the member is financially responsible for the specific service. This must be completed prior to providing the service and the member must sign and date the notification. CareSource members are not responsible for any co-payments on Medicaid services provided by CareSource. Please see the Member Billing Policy for full details.

Providers can obtain Prior Authorization for health care services by contacting the CareSource Medical Management Department by phone, fax, mail, online Provider Portal or e-mail. Requests can be submitted on the Prior Authorization Request Form.

Submit a PA Request:

• Online Prior Authorization
• By phone: 1-800-390-7102
• By fax: 1-888-577-5507
• By mail:
  

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

A referral is required for CareSource members to be evaluated or treated by most participating specialists. A Prior Authorization is needed to refer a member to a non-participating provider. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the PCP. Please see the CareSource Provider Manual for more details.

Yes. Prior authorization is required for outpatient, non-emergent diagnostic procedures. Please refer to our section on Prior Authorization for how to submit, and what requires Prior Authorization.

Authorization for an observation stay in a participating facility is not required. An observation in a non-participating facility does require an authorization and must be reported to Medical Management for medical necessity review.

Prior Authorization is not required when CareSource is the secondary payer for medical services.

Prior Authorization is required for any dental request listed on the Prior Authorization list when CareSource is the secondary payer.

Providers have 180 days from the date of service, date of discharge or 180 days from another carrier’s denial on an Explanation of Payment (EOP) whichever is later to request a retrospective review for medical necessity. The retrospective review requests must include a copy of the other carrier’s EOP. All requests for services will be reviewed for timeliness and medical necessity.

Providers can request a retrospective review by contacting the Medical Management Department at 1-800-390-7102, or by faxing the request to 1-888-527-0016. Clinical information supporting the request for services must accompany the request.

CareSource offers its members many extra benefits and support services, such as a 24/7 nurse advice line, free transportation to doctor appointments, case management, coupons for keeping prenatal and postpartum appointments for pregnant members and more. Visit our Covered Services section for more details, or visit our Covered Services Grid to see benefit limits on select services.

Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare Managed Care Plans. The only exception is BCMH (Bureau for Children with Medical Handicaps), where Medicaid would be considered primary.

It is the responsibility of the provider to verify and obtain all Coordination of Benefits information at time of service. There are two ways to verify, check online or call:

• Online: Visit the Provider Portal to view the Coordination of Benefits information that CareSource has on file for the member.
• By phone. Call 1-800-390-7102 and follow the menu prompts.

Coordination of Benefits claims should be submitted by mail with the Explanation of Benefits and mailed to:

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

Take me to a form: 1500 Claim form, UB-04, ADA J400

Submit a copy of the Explanation of Benefits by email, fax or mail:

• By email: Email COBMichigan@caresource.com
• By fax: Fax (937) 396-3140
• By mail:
  

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

Call Provider Services: 1-800-390-7102. Once CareSource confirms that the member no longer has primary coverage, the member is updated in our system.

Check the carrier’s website or call the carrier directly to obtain the information. We encourage all providers to verify the patient’s insurance coverage at the time of service.

365 days from the Date of Service, OR 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater.

If you are not able to submit a claim according to our filing deadline of 365 days, we will accept 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater. Simply submit a copy of the primary carrier’s EOB to CareSource.

Online. You can obtain the other coverage information that CareSource has on file by reviewing the member's eligibility information on our Provider Portal.

By phone. Call 1-800-390-7102 and follow the menu prompts.

There are two sources where takeback/recoupment information may come from:

1) Health Management Systems (HMS)
HMS is our third party vendor that identifies a patient has a primary insurance.

Please send documentation to HMS within 30 days of the recoupment letter. Documentation is typically an EOB showing coverage was not in effect, services were paid, or services denied.

Third Party Recovery Unit
Attn: CareSource COB Project HMS, Inc.
5615 High Point Drive
Suite 100
Irving, TX 75038
(877) 259-3308
Fax: (314) 905-2064

2) Recoupment/Takebacks from CareSource
CareSource will initiate an automatic recoupment in 30 days from the date of notification. If you are disputing the information, send supporting documentation directly to CareSource within 60 days of the recoupment letter date. Documentation is typically an EOB showing coverage was not in effect, services were paid, or services denied.

Send this to:

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

No, you do not need to send a refund check or initiate an adjustment request on these claims. The recoupment will be made against future claims payment and will show on the Explanation of Benefit.

CareSource needs a copy of the primary carrier's Explanation of Benefits denying the claim in order to process it within 365 days of our timely filing guidelines:

• The member did not supply the requested information (For example, accident/injury questionnaire, full-time student questionnaire).
• Procedural denial reasons (For example, timely filing, prior authorization, no referral from Primary Care Provider).

Providers must comply with the plan rules of the primary insurance carrier. If the primary carrier makes payment on the claim, a second authorization from CareSource is not required. The claim should then be submitted to CareSource as secondary. We will reimburse for this service if the primary payment is less than our allowable rate. If the primary denies the claim for procedural reasons, CareSource becomes the primary plan and therefore, prior authorization would be required.

When CareSource Will Automatically Adjust a Denied COB Claim:

CareSource will automatically adjust the claims that originally denied for COB when the following criteria are met:

• Primary insurance has been updated retroactively to show coverage terminated AND
• The claim was denied for COB within 90 days of receiving the updated information that the primary coverage has been terminated

Example:

• Claim for date of service 6/15/10 was denied on 7/10/10 due to the member having primary coverage effective 1/1/10.
• CareSource received notification on 9/1/10 that the other coverage terminated on 5/31/10.
• Since the claim was originally processed within the 90 day period of receiving the notification that the primary coverage was terminated, CareSource would automatically adjust the claim.

When CareSource Will NOT Automatically Adjust a Denied COB Claim:

If the updated coverage was received after 90 days from the denial for COB, the provider still needs to notify CareSource within 365 days of date of service that the claim is COB. OR, the provider still needs to notify CareSource within 90 days from the date of the primary EOB denial, whichever is greater.

Claim for date of service 12/1/09 was denied on 1/10/10 due to member having primary coverage effective 1/1/09, and the EOB was not attached to the claim.

• CareSource received notification on 9/17/10 that the primary coverage terminated on 7/31/09.
• Since the claim was denied for COB after 90 days of receiving notification that primary coverage was terminated, the claim would not be automatically adjusted.
• However, if the provider contacts us by 12/1/10 or within 90 days of the EOB, the claim will be adjusted.

Although CareSource is implementing this COB Adjustment Policy, it is still the provider's responsibility to review their accounts and submit COB claims in a timely manner for payment.

This is effective September 1, 2010, for Michigan Providers.

• All CareSource claims: clean, coordination of benefits corrected will now be accepted 365 days from the date of service (previously 180 days)
• Claim appeals will now be accepted 365 days from the date of service or discharge (previously 90 days)
• Medical necessity claims will be accepted for 180 days from date or service, date of discharge or date of denial if service was not yet rendered (previously 90 days)

Days will be counted from the date of service, or the discharge date, whichever is greater.

Providers should always ask their CareSource patient if they have more than one insurance plan since Medicaid is the last to pay by federal law. This new timeline gives the provider ample time to bill the primary payer, receive rejections (if there are any) and submit the claim to CareSource for processing.

Identify the claim as “Corrected” when resubmitting to CareSource. Providers have 365 days from the date of service to submit a corrected claim.

Providers should contact Provider Services at 1-800-390-7102.

CareSource is a non-profit Medicaid managed care organization that serves Michigan Medicaid consumers. We contract with the Michigan Department of Community Health (MDCH) to provide services. Our focus is on prevention and partnering with local health care Providers to offer the services our members need to remain healthy.

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:

• Prompt claims payment
• Claims call center
• Paperless referrals and low-hassle medical management
• Web-based transactions and electronic claims submission
• Secure provider portal available 24/7 where providers can perform a variety of functions, including checking eligibility, claim status, submit prior authorization and more
• Provider relations staff
• Commitment to service
• Member support services

Providers can visit our provider services section to learn how to contract with CareSource. Or, call Provider Services at 1-800-390-7102 and we can give you the information you need to start the process of becoming a participating provider.

Call Provider Services at 1-800-390-7102, Monday through Friday, 8 a.m. to 5:30 p.m., except holidays. Follow the menu options to speak to a representative from the department you need.

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

Specialists document the referral in the member's chart as well. Referral forms are not required.

For more information, please see Referrals and Prior Authorizations of the Provider Manual.

There is no difference in the information you will receive.

If the zeros are omitted they will be added automatically.

The primary user cannot reset their password. For assistance with resetting your password, please contact Provider Services at 1-800-390-7102.

After logging into the Provider Portal, the primary user can add additional users through the “manage users” tab in the left navigation menu.

This is now called CareSource Provider ID, which is the same thing.