Frequently Asked Questions
General questions
Billing
Claims
Appeals
Benefits
Authorizations
Member eligibility
Website questions
General questions
What is CareSource?
CareSource is a non-profit managed health care organization that serves consumers of:
- Covered Families and Children Medicaid
- Healthy Start and Healthy Families Medicaid
We contract with the Ohio Department of Job and Family Services (ODJFS) 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.
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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:
- Prompt claims payment
- Claims call center
- Paperless referrals and low-hassle medical management
- Web-based transactions and electronic claims submission
- Provider relations staff
- Commitment to service
- Member support services
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How can I become a participating provider?
Call Provider Management at 1-877-725-4577. We can give you the information you need to start the process of becoming a participating provider with CareSource.
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How can I reach CareSource?
Call Provider Services at 1-800-488-0134, Monday through Friday, 8 a.m. to 6 p.m., except holidays. Follow the menu options to speak to a representative from the department you need.
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What services are available on the CareSource IVR?
Our automated telephone service offers eligibility information for CareSource members 24 hours a day. To obtain automated eligibility for dates of service beginning today, or any day in the last 12 months, call Provider Services and follow the "eligibility" menu options. Be sure to have the CareSource member ID and date(s) of service available.
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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.
Specialists document the referral in the member's chart as well. Referral forms are not required.
For more information, please see Section 7 (Referrals and Prior Authorizations) of the Provider Manual.
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Billing
Can I ever bill my CareSource patients?
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 and the provider notifies 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. Please see Member Billing Policy for full details.
For dates of services for a retrospective review that are on or past 12/1/09 providers have 90 days from the date of service or 90 days from another carrier’s denial on an Explanation of Payment (EOP) to request a retrospective review for medical necessity. In this instance, the retrospective review request 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 1-800-488-0134 and following the appropriate menu prompts, or by faxing the request to 1-888-527-0016. Clinical information supporting the request for services must accompany the request.
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How do I submit a retro authorization?
A retrospective can be faxed to the dedicated fax number of 1-888-527-0016 with the supporting clinical information.
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What is the turnaround time for a retro request?
A retrospective review will be completed within 30 calendar days from the receipt of the request.
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Do you have a list of codes that require authorization?
Currently we do not have an inclusive list of all procedure codes that require an authorization.
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Can I ever bill my CareSource Medicaid patients?
State and federal regulations prohibit health care providers from billing CareSource Medicaid members for services provided to them unless they agree in writing to pay for a specific service before it is rendered. CareSource Medicaid members are not responsible for any co-payments. Please see Member Billing Policy for full details.
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Claims
How do I submit a claim?
CareSource accepts paper and electronic claims. We encourage you to submit electronic claims for quicker processing. Please see How to Submit a Claim for more information.
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How can I optimize my claim payment timeframe?
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.
CareSource uses OCR/ICR (optical/intelligent character recognition) systems to capture claims information. This technology increases efficiency, improves accuracy and results in faster processing times.
Please adhere to the following requirements to ensure timely processing of your claim. Claims that do not meet these requirements may be significantly delayed in processing:
- 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
- Including your 12 digit CareSource provider ID allows for fastest paper claim processing
- In general, using clean claim forms with legible print will allow for more efficient processing
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How soon will I know if my claim was paid?
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.
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What options do I have to check more than three claim statuses at once?
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 with the weekly check write.
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What is the filing limit with or without COB?
Claims must be submitted to CareSource within 180 days of the date of service. When CareSource is the secondary payer, claims older than 180 days may be submitted to CareSource within 90 days of the date of primary carriers EOP.
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Appeals
How do I file an appeal?
We hope you will be satisfied with CareSource and the service we provide. However, providers who are unhappy with CareSource's action concerning a medical necessity decision or a claim payment may appeal it. Please see How To File an Appeal for more information.
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Benefits
Does CareSource offer additional services?
Yes! CareSource offers its members many extra benefits and support services, such as a 24-hour nurse advice line and transportation to some health-related appointments. For more information, please see Additional Services.
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Authorizations
How do I obtain Prior Authorization?
Providers can obtain Prior Authorization for health care services by contacting the CareSource Medical Management Department by phone, fax, mail or e-mail:
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Online Prior Authorization
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By phone. Call 1-800-488-0134 and follow the menu prompts to the specific prior authorization option required.
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By fax. Fax medical, including specialty drug, and dental requests to the CareSource Medical Management Department at 1-888-752-0012.
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By mail. Send Prior Authorization requests to:
CareSource
P.O. Box 1307
Dayton, OH 45401-1307
For more information related to Pharmacy Prior Authorization requests, follow the Ohio Medicaid Drug Program link below.
http://jfs.ohio.gov/ohp/bhpp/meddrug.stm
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Is authorization needed for referrals to specialists?
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 an out-of-plan provider. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the PCP. Please see Section 7 of the CareSource Provider Manual for more details.
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Is authorization needed for outpatient, non-emergent diagnostic procedures?
Yes. Effective July 1, 2009, prior authorization is required for outpatient, non-emergent diagnostic procedures. Please refer to our Radiology Benefit Management Program for more information.
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Is authorization required for an observation?
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.
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Does CareSource require authorization if the member has primary insurance?
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 secondary.
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Member eligibility
Why can't I check the future eligibility for a member?
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.
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Can a member be retro termed?
Yes, a member's eligibility can be retro termed at any point during the month by the Ohio Department of Job and Family Services (ODJFS).
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How do I check member eligibility?
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. For more information, please see How To Check Member Eligibility.
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Can I see a member if my name is not on the member card?
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, be advised eligibility does not guarantee payment of the claim.
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Website questions
Is there a difference in the info I get if I sign up as a provider or as a Group?
There is no difference in the information you will receive.
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Why is the member ID number I am using not pulling up the member?
This error is generally caused by omitting the two zeros (00) necessary at the beginning of the member ID.
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How can I reset my password if I don't remember it?
The primary user cannot reset their password. For assistance with resetting your password, please contact Provider Services at 1-800-488-0134.
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How can I add additional users?
After logging into the Provider Portal, the primary user can add additional users through the manage users tab in the left navigation menu.
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What is an affiliation number?
Your affiliation number is a unique identification number assigned to you by CareSource. This affiliation number can be found on your contract.
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