Prior Authorization
CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.
Prior Authorization Submission Options
The Provider Portal is the preferred and faster method to request prior authorization for health care services. You can receive immediate approval and also review the status of an authorization.
| Method | Contact Info |
|---|---|
Provider Portal (Preferred) | If you need assistance with submitting your prior authorization or have questions regarding submissions via the Provider Portal, please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. |
Phone | |
Fax | 1-888-752-0012 |
CareSource |
Please note: Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.
Non-Participating Providers
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:
| Service Type | Contact Information |
|---|---|
Emergency Use of emergency services does not require authorization. Admissions that result from emergency room visits do require authorization. | |
Post Stabilization Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider. |
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- MRI/MRAs
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.