Provider Services
CareSource's foundation is our strong partnership with participating health care providers. In partnership with you, we fulfill our mission of making a difference in the lives of underserved people by improving their health care.
Because the satisfaction of our health care providers is so important to us, we offer a wide array of services and benefits, including:
How to reach us
Call Provider Services toll-free at 1-800-488-0134.
Our friendly and knowledgeable representatives are available to speak with you from 8 a.m. to 6 p.m., Monday through Friday, except holidays.
You can call Provider Services with questions or issues about covered services, procedures or services that require Prior Authorizations, member eligibility, basic reimbursement rate inquiries and other CareSource policies. Please have the name and CareSource member ID number for the member you are calling about ready when you call.
Enhanced reimbursement
CareSource offers a competitive reimbursement for its valued providers.
We also offer a performance bonus to Primary Care Providers for providing certain well-child checkups and immunizations. For more information, please contact your Provider Relations Representative.
Provider Portal
CareSource's secure online Provider Portal makes it easier for you to work with us. The portal is easy to access, whenever it is convenient for you. This helpful online tool is available for all CareSource health care plans. Assisting you is one of our top priorities in order to deliver better health outcomes for our members. If you are a registered user, or want to become one, please click on Provider Login to perform a variety of web-based transactions such as:
- Claims Status
- Member Eligibility
- Prior Authorizations (medical only)
- Member Profile - New Feature!
- Member Rosters
Provider Relations
Interested in becoming a participating health care provider? Do you have a question about your contract with CareSource? Would you like us to conduct an orientation for your office? Do you have a reimbursement issue?
Whatever the question, our Provider Relations Department is here to serve you. Just call Provider Services at 1-800-488-0134. Ask to speak with the Provider Relations Representative assigned to you.
CareSource 24
Experienced registered nurses are available 24 hours a day, 7 days a week to provide symptom-based triage and health education to CareSource members.
Health care counseling and telephone triage helps assess health status and provides immediate health information, guiding members to the appropriate level of care. Members can then be referred or routed to other CareSource services that may be beneficial to them. This coordination between CareSource departments helps maintain continuity of care.
Our nurses help members:
- Decide when self-care, a doctor visit or the emergency room is appropriate
- Understand a medical condition or recent diagnosis
- Prepare questions for doctor visits
- Find out more about prescriptions or over-the-counter medicines
- Get information on diagnostic or surgical procedures
- Learn about nutrition and wellness
Members can call CareSource 24 at 1-866-206-0554.
Medical Management/Specialty Drug Management
The Medical Management Department is responsible for health care resource utilization review and monitoring the health care provided to our members. Some health care services, including some medications and supplies must be authorized by our Medical Management team before they can be provided to a CareSource member.
Please contact the Medical Management Department for services that require Prior Authorization such as hospital admissions and benefit limit extensions.
Care management and outreach
Care management plays a key role in our services to CareSource members. Nurses and social workers are available to assist your CareSource patients in coordinating appropriate medical and support services.
Our focus is on helping our members acquire and maintain effective management of their condition through assessment, coordination of care, education and support.
Our Care Management program focuses on members with:
- Special health care needs
- Asthma
- Diabetes
- Congestive heart failure
- Pain Management
- Pregnancy
- Weight Management
We work in partnership with you to encourage compliance with treatment plans, reinforce medical instructions and access social needs. Please contact us to identify a CareSource member who may benefit from care management.
Please see Covered Services for information about the other member support services CareSource offers.
Dispute resolution
Provider disputes
Provider disputes for issues related to clinical, quality, professional competency or conduct should be sent to:
CareSource
P.O. Box 8738
Dayton, OH 45401-8738
Provider disputes for issues that are contractual or non-clinical should be sent to:
CareSource
Attn: Provider Relations
P.O. Box 8738
Dayton, OH 45401-8738
CareSource reserves the right to immediately suspend or summarily dismiss, pending investigation, the participation status of a participating provider, who, in the opinion of the CareSource Chief Medical Officer is engaged in behavior or who is practicing in a manner that appears to pose a significant risk to the health, welfare, or safety of our members. Any participating provider that is subject to a suspension or termination may dispute the action and request a hearing through the CareSource Fair Hearing Plan.
Appeals procedures
Appeals of claims denials or adverse decisions (Medicaid and Medicare)
An adverse decision regarding payment for a submitted claim or a denied claim for services rendered to a CareSource member can be appealed if the request for appeal is made within 90 days of receiving notification of the adverse action. Appeals of claims decisions should include the member's name, identifying information, date(s) of service, the service being appealed, and the reason to reconsider the decision. Providers will be notified of the resolution.
Claims appeals should be addressed to:
CareSource
Attention: Claims Appeal Coordinator
P.O. Box 2008
Dayton, OH 45401-2008
For additional information about appeals please refer to the Appeals Procedures section of the Provider Manual.