Prior Authorization

We are dedicated to supporting your efforts to make sure CareSource members receive the most appropriate care in the most appropriate setting for their needs. Prior Authorization is based on a combination of medical necessity, medical appropriateness and benefit limits.

Our Covered Services Grid indicates which services require Prior Authorization.

Ordering physicians must obtain a prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:

  • MRI/MRAs
  • CT/CTA scans
  • PET scans

The following services also require a prior authorization:

  • All Abortions
  • All Inpatient Care
  • Some Home Care Services
  • Inpatient Rehabilitative Services
  • Nursing Facility Services
  • Organ Transplants
  • Durable Medical Equipment and other supplies over $750.00 billed charges
    • The $750.00 rule does not apply to the following DME/other items (these require prior authorization):
      • All powered or customized wheelchairs
      • Manual wheelchair rentals over 3 months
      • Hearing Aids
      • Contact Lenses
      • All  miscellaneous codes (example E1399)
  • Greater than 10 Fetal Non-Stress Tests per pregnancy
  • Cosmetic procedures and plastic surgery
  • Some specialty drugs
  • Ambulance and ambulette transportation – except for emergent or facility- to-facility transfers
  • Services beyond benefit limits for members 20 years of age and under: This includes chiropractic care, dental care, optometry services, some mental health services, physical/occupational therapy, and speech therapy/hearing testing beyond benefit limits.
  • Food supplements/nutritional supplements
  • Infant formula (PA required for >30 cans per month)

Any health care provider who is not participating with CareSource must obtain prior authorization for all non-emergency services rendered to a CareSource member.

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.

Note: 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.

Certain Dental Services also require Prior Authorization.

Attention non-participating providers

Emergency Services – All in-patient services require prior authorization. Please call 1-800-488-0134 to obtain prior authorization for emergent admissions. Outpatient emergency services do not require prior authorization. Please submit claims electronically or for paper claims send to:


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

Post Stabilization Services – Please call 1-800-488-0134 for post stabilization services if the member requires inpatient care for covered services related to an emergency medical condition that a treating provider views as medically necessary after an emergency medical condition has been stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 C.F.R. 422.113 to improve or resolve the member's condition. Such services shall be deemed prior authorized if CareSource does not respond within the one-hour timeframe for responding to a request for authorization being made by the emergency department.

Radiology Benefit Management Program

Program summary

On July 1, 2009, CareSource implemented a Radiology Benefit Management Program requiring Prior Authorization for CT, MRI and PET scans, in partnership with National Imaging Associates, Inc. (NIA).

Effective for scans or studies performed on or after July 1, 2009, ordering physicians must obtain a Prior Authorization for the following non-emergent, outpatient diagnostic imaging procedures*:

  • MRI/MRA scans
  • CT/CTA scans
  • PET scans

*A separate authorization number will be required for each procedure ordered.

Note: Imaging procedures performed during an inpatient admission, hospital observation stay, or emergency room visit are not included in this program.

Ordering physicians

As a physician ordering advanced radiology procedures for CareSource members, you are responsible for obtaining Prior Authorization before scheduling an imaging exam for the non-emergent, outpatient diagnostic procedures listed above. It is essential that you ensure that the appropriate authorization number(s) has been obtained. Payment will be denied for procedures performed without a required Prior Authorization, and the member cannot be balance-billed for such procedures.

Rendering/servicing facilities

It is the responsibility of the rendering facility to confirm that Prior Authorization was obtained prior to performing the diagnostic procedure.

Issuance of an authorization is not a guarantee of payment. When submitted, the claim will be processed in accordance with the terms of the member's health benefit plan.

Prior Authorization process for advanced imaging procedures

There will be two ways ordering physicians can obtain Prior Authorization from NIA for an imaging procedure:

  • Online via www.radmd.com
  • By Phone – 1-800-488-0134 (follow the options to obtain a Prior Authorization and select the option for advanced radiology prior authorization), Monday through Friday, from 8 a.m. to 8 p.m. EST

Authorization requests are approved at intake in most cases. If an approval cannot be issued during the initial intake, more information may be required. These determinations are generally made within two (2) business days after receipt of request. In certain cases, the review process may take longer if additional clinical information is required to make a determination.

Submitting claims

Claims will continue to go directly to CareSource. Please send your claims for imaging procedures to the following address:


CareSource
Attn: Claims Dept.
P.O. Box 8730
Dayton, OH 45401-8730
Providers are encouraged to use EDI claims submission.

Radiology Benefit Management Program resources

Radiology Safety Awareness Information

Who do I call with questions?

Please contact Stephanie Martin, NIA Provider Relations Manager, at (410) 953-2631.

You may also contact your designated CareSource Provider Relations Representative for more information about CareSource's Radiology Benefit Management Program.

Referrals

CareSource uses a paperless referral system to make it easy for Primary Care Providers (PCPs) to refer their patients to participating CareSource specialists. PCPs may only refer members to another provider who also participates with CareSource unless special circumstances exist, in which case Prior Authorization is needed.

Please follow these steps to make a referral:

PCP: Document the referral in the patient's medical chart. No forms or referral numbers are required. However, you must notify the specialist of your referral.

Specialist: Document in the patient's chart that the patient was referred to you for services. Referral numbers are not required on claims submitted for referred services. Generally, only PCPs can issue referrals to additional specialists and 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 referral procedures as well as for a list of services that do not require a referral please refer to the Referrals and Prior Authorizations section of the Provider Manual.