CareSource is committed to maintaining the quality and appropriateness of health care services provided to our members. The Medical Management department performs all utilization management (UM) activities including prior authorization, concurrent review, discharge planning and other activities. CareSource makes its UM criteria available in writing by mail, fax, phone or email and on this webpage.
Attn: Medical Management Dept.
P.O. Box 44493
Dayton, OH 45401-1307
On an annual basis, CareSource completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.
Medical Necessity Criteria
CareSource utilizes nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. CareSource defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. CareSource also has policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a CareSource Medical Director for further review and determination. Physician reviewers from CareSource are available to discuss individual cases with attending physicians upon request.
Utilization review determinations are based only on appropriateness of care and service and existence of coverage. CareSource does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.
Our members’ health is always our number one priority. Upon request, CareSource will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CareSource Medical Management Department. If you would like to discuss an adverse decision with physician reviewer, please call the Medical Management department at 1-888-880-4889 within five business days of the determination. Please wait for the announcement to complete from our automated system, Katie, and then state the word “extension” and you will then be prompted to voice the extension number. Ask for 12830 and you will then be forwarded to the peer extension line.
Access to Staff
Providers may call our toll free number at 1-888-880-880-4889 to contact Medical Management staff with any UM questions.
- Staff members are available from 8 a.m. to 5 p.m. Eastern Standard Time (EST) Monday through Friday for inbound calls regarding UM issues.
- Staff members can receive inbound communication regarding UM issues after normal business hours.
- Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, 7 days a week.
- Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line, email and the Provider Portal.
- Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
- Staff members are identified by name, title and organization name when initiating or returning calls regarding UM issues.
- Staff members are available to accept collect calls regarding UM issues.
- Staff members are accessible to callers who have questions about the UM process.
In the best interest of our members and to promote their positive health care outcomes, CareSource supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.
Member Support Services
Representatives are available to answer member questions regarding UM.
- Representatives are available by telephone Monday through Friday, except on the following holidays in 2018: New Year’s Day (Jan. 1), Martin Luther King Jr. Day (Jan. 15), Memorial Day (May 28), Independence Day (July 4), Labor Day (Sept. 3), Thanksgiving Day (Nov. 22), and Christmas Day (Dec. 25).
- Members may access Member Services by calling our toll-free number, 1-844-607-2829, 8 a.m. to 8 p.m. (TTY for the hearing impaired: 1-800-743-3333 or 711) and following the menu prompts.
- CareSource offers language interpreters for members who need assistance to communicate with CareSource to discuss UM issues. These services are available at no cost to the member. As a provider, you are required to identify the need for interpreter services for your CareSource patients and offer assistance to them appropriately.