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Claim Payment Policies

CLAIM & PAYMENT POLICIES

Out-of-Network Liability

If you receive emergency care from a provider who is not a network provider or urgent care services outside the service area, you will need to submit the bill you receive to CareSource with a claim form. You may also obtain a claim form by calling Member Services the number on the back of your ID card.

Claims

Your provider is responsible for requesting payment from us. If your provider is unable to submit claims, you may submit a claim directly to us using the member claim form or by calling Member Services.

Written notice of claim must be given to us within 60 days from the date services were rendered, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the member to CareSource or to any authorized agent of CareSource, with information sufficient to identify the member, shall be deemed notice to us.

Submit claims to: CareSource, P.O. Box 8738, Dayton, OH 45401-8730

Grace Period

If you pay a premium for any period of time after your coverage is terminated, we will refund that premium to you. The refund will be for the period of time after your coverage ends.

If at least one full month’s premium has been paid during the benefit year, we will observe a grace period of three consecutive months for the payment of any premium.

During this three-month grace period, we will:

If you do not pay a premium for any period during the benefit year, any health care services received during such period will not be covered. The grace period provisions above will not apply to you. You are responsible for the costs of any health care services that you receive for any period of time during the benefit year for which you did not pay a premium. Your provider(s) will bill you for such non-covered health care services, and you will be responsible for directly paying your provider(s).

Retroactive Denials

If we authorize a proposed service to be provided by a network provider based upon the complete and accurate submission of all necessary information relative to a covered person, we will not retroactively deny this authorization if the network provider renders the health care service in good faith and pursuant to the authorization and all of the terms and conditions of the Evidence of Coverage (EOC) and the network provider’s contract with us. If coverage is retroactively terminated, then the payment will be recouped from the provider. You will be notified of a retroactive denial by an Explanation of Benefits (EOB).

Recoupment of Overpayments

If you received an invoice with a credit balance shown, this represents money owed to you. We can apply the balance toward future premium amounts or refund the money to you at your request. If you choose to receive a refund, please contact Member Services at the number on your ID card between the hours of 7 a.m. and 7 p.m. Monday through Friday. A refund will be sent to you within 30 days. If your coverage has been terminated, any refunds of premiums that may be due will be generated and sent to you within 60 days.

Medical Necessity and Prior Authorization Timeframes

Medically necessary services are health care services that are determined to be medically appropriate in accordance with CareSource’s medical policies and nationally recognized guidelines. These are services that are not experimental or investigational in nature, are necessary to meet the basic health needs of the covered person and are rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service.

Medically necessary services are consistent in the type, frequency and duration of treatment with scientifically-based guidelines of national medical, research or health care coverage organizations or governmental agencies that are accepted by us; they are consistent with the diagnosis of the condition; are required for reasons other than the convenience of the covered person or his/her physician; and are demonstrated through prevailing peer-reviewed medical literature to be either:

CareSource must make decisions on services that require a prior authorization within specific timeframes.

 

A request for prior authorization must be made, decided and a benefit determination issued, as expeditiously as the member’s health condition requires, but no later than two business days following receipt of the complete request. If your network provider fails to obtain prior authorization from us for health care services as required by us, and such provider renders such health care services, then neither the plan nor you will be required to pay for such health care services.

An urgent determination must be reviewed, completed, decided and a benefit determination issued as fast as is needed, but no later than 72 hours following receipt of the request.

YOUR RESPONSIBILITIES

Be Enrolled and Pay Required Premiums

Benefits are available to you only if you are enrolled for coverage under the plan. To be enrolled under the plan and receive benefits, your enrollment must be in accordance with the plan’s and the Health Insurance Marketplace’s eligibility requirements, as applicable. You must also qualify as a covered person. You must also pay any premiums required by the Marketplace and/or the plan.

Choose Your Health Care Providers

It is your responsibility to select the network providers and network pharmacies that will provide your health care. We can help you find network providers and network pharmacies. Use the Quick Links to access our Find a Doctor/Provider tool and our Find a Pharmacy tool.

Your Financial Responsibility

You must pay copayments, coinsurance and the annual deductible for most covered services. 

If you are a member of a federally recognized tribe and your household income is at or below 300% of the federal poverty level, you will have no cost sharing (including copayments, coinsurance, and deductibles) for covered services. More information, including a list of federally recognized tribes, is available online at: healthcare.gov. Regardless of your household income, there is no cost sharing if you receive services from an Indian health care provider or through referral under the Contract Health Services program administered by the Indian Health Service.

Pay the Cost of Limited and Excluded Services

You must pay the cost of all health care services and items that exceed the limitations on payment of benefits or are not covered services. 

Show Your ID Card

To make sure you receive your full benefit under the plan, you should show your ID card every time you request health care services. If you do not show your ID card, your provider may fail to bill us for the health care services delivered. Any resulting delay may mean that you will not receive benefits under the plan to which you would otherwise be entitled.

Exceptions

Sometimes a member may have a drug allergy or intolerance. Or, a certain drug may not be effective for a member. In these cases, the member or the member’s representative may ask for an exception to a drug listed on the PDL. The member or member’s representative can call Member Services at the number on the CareSource ID card to make the request, or complete the online Member Exception Request for Non-Formulary Medication.

CareSource then contacts the appropriate health partner. CareSource may ask the health partner to provide written clinical documentation about why the member needs an exception. Health partners must provide this information.

CareSource will provide a decision no later than 72 hours after the request is received. If the member is suffering from a serious health condition, CareSource will provide a decision within 24 hours. As part of the process, CareSource will consider whether the requested drug is clinically appropriate.

Explanation of Benefits

After you receive health care services, you will generally receive a written Explanation of Benefits (EOB) summarizing the benefits you received. This EOB is not a bill for health care services.

The EOB shows you what services were billed to CareSource and how they were paid. It lists:

Click here for an example of an EOB.

If you do owe for a service, you will get a bill from the provider. We encourage you to save these EOB statements and pay only the amount listed as your responsibility. If you get a bill from a provider for more than the amount the EOB shows as your responsibility, please call Member Services at 1-800-479-9502 (TTY: 1-800-750-0750 or 711).

Coordination of Benefits

Coordination of Benefits (COB) is the process used to determine which health plan or insurance policy will pay first and/or determine the payment obligations of each health plan, medical insurance policy or third party resource when two or more health plans, insurance policies or third party resources cover the same benefits.

The Order of Benefit Determination Rules govern the order in which each health plan will pay a claim for benefits. The health plan that pays first is called the primary health plan. The primary health plan must pay benefits in accordance with its policy terms without regard to the possibility that another health plan may cover some expenses. The health plan that pays after the primary health plan is the secondary health plan. The secondary health plan may reduce the benefits it pays so that payments from all health plans do not exceed the primary health plan’s maximum allowable amount.

Refer to your EOC on the Plan Documents & Resources page for more information.

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