Utilization Management

    CareSource PASSE™ is committed to ensuring the quality and appropriateness of health care services provided to our members. The Utilization Management department performs all utilization management (UM) activities including prior authorization, concurrent review, discharge planning and other activities. CareSource PASSE makes its UM criteria available in writing by mail, fax, phone or email and on this webpage.

    • Mail: CareSource PASSE
      Attn: Utilization Management Dept.
      P.O. Box 1307, Dayton OH 45401
    • Fax: 844-542-2608

    On an annual basis, CareSource PASSE completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

    Prior Authorization

    CareSource PASSE understands that you may have questions about prior authorization. Please visit our Prior Authorization webpage for more information.

    Medical Necessity Criteria

    CareSource PASSE utilizes nationally recognized criteria to determine medical necessity of inpatient hospital and rehabilitation admissions These criteria are designed to assist health care providers 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 PASSE defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. CareSource PASSE 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 PASSE Medical Director for further review and determination. Physician reviewers from CareSource PASSE are available to discuss individual cases with attending physicians upon request.

    Utilization review determinations are based only on medical necessity and existence of coverage. CareSource PASSE does not reward health care providers 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 PASSE will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CareSource PASSE Utilization Management department. If you would like to discuss an adverse decision with physician reviewer, please call the Utilization Management department at 1-833-230-2100 within five business days of the determination.

    Access to Staff

    Providers may call our toll-free number at 1-833-230-2100 to contact Utilization Management staff with any UM questions.

    • Staff members are available from 8 a.m. to 5 p.m. Central Time (CT) 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 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 PASSE’s Care Coordinators support and encourage continuity of care and coordination of care amongst the system of care that supports our members.

    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 2021:
      • New Year’s Day (January 1)
      • Memorial Day (May 31)
      • the day after Independence Day (July 5)
      • Labor Day (September 6)
      • Thanksgiving Day (November 25)
      • the day after Thanksgiving (November 26)
      • the day before Christmas Eve (December 23)
      • Christmas Eve (December 24)
    • Members may access Member Services by calling our toll-free number, 1-833-230-2005, Monday through Friday, 8 a.m. to 5 p.m. Central Time (CT) (TTY for the hearing impaired: 1-800-285-1131 or 711) and following the menu prompts.
    • CareSource PASSE offers language interpreters for members who need assistance to communicate with CareSource PASSE 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 PASSE patients and offer assistance to them appropriately.