Claim Submission

CareSource accepts both 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
  • 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.

Claim submission timeframes

Claims must be submitted within 365 days of the date of service. We will not be able to pay a claim if there is incomplete, incorrect or unclear information on the claim. If this happens, Providers have 365 days from the date of service to submit the information needed for processing the claim.

For more information on Timely Filing please see the FAQs.

Claim forms

CareSource accepts 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 - UB-04, formerly UB92 form (for hospitals)
  • ADA Dental Form - for dental claims, use most current version

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

All claims must include:

  • Patient (member) name
  • Member's CareSource ID number
  • Member's complete address
  • Member's date of birth
  • Other insurance information, if applicable
  • Place of service. Please use current 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
  • Billed charges for each service line
  • Total charge for claim
  • Federal tax ID number
  • National Provider Identifier (NPI) number (required for electronic claims)
  • Provider's signature
  • For prenatal or delivery services, the last menstrual period date is required on claims. Providers may estimate this date if necessary based on the gestational age of the child

We recommend you include your CareSource Provider Billing Number on all claims. If you are unsure of you Provider Billing Number, please call 1-800-488-0134.

Please send all paper claims to:

CareSource
Attn: Claims Department
P.O. Box 8730
Dayton, OH 45401-8730

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.

Appeals

If CareSource denies a claim, providers have 365 days from the date of service to appeal a claim. 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.

National Provider Identification (NPI) number

To comply with the national mandate for NPI (National Provider Identifier), effective May 23, 2008, CareSource requires that your NPI number and Tax ID number be included on all electronic claims.

Claims that do not include your NPI and Tax ID will be rejected.

We strongly encourage you to submit your CareSource provider ID on the claim, in addition to your required NPI and Tax ID numbers.

Please confirm these billing arrangements with your billing team and any claims clearinghouse.

The latest claim forms include a position for the NPI. Instructions for completing the following claim forms can be found online:

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)