Provider Disputes and Appeals

Definitions

CareSource PASSE™ provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Claim Disputes

A dispute is the first formal review of the processing of a claim by CareSource PASSE (excluding denials based on medical necessity) and is typically submitted prior to submitting a claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial.

Claim Appeals

A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors.

Peer-to-Peer

Peer-to-peer rights are separate and distinct from your clinical appeal rights. If you received an authorization denial, your peer-to-peer rights were provided in your denial letter from CareSource PASSE. Please refer to your denial letter to exercise your available peer-to-peer rights. CareSource PASSE provides peer-to-peer reviews as an additional level of review for your pre- or post-service medical necessity requests, and they must be completed prior to you submitting a clinical appeal.

Clinical Appeals

A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the CareSource PASSE Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are clinical appeals and require the member’s written consent. For more information about requirements for pre- and post-service appeals, view the Clinical Appeals section below.

Claim Disputes

If you believe the claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You do not need to file a dispute or appeal. Corrected claims should not be submitted as part of an appeal or dispute. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Process for Claim Disputes

If you believe your claim was denied incorrectly or underpaid, you can submit a claim payment dispute. Claim payment disputes must be submitted in writing with supporting documentation.

Claim disputes must be submitted in writing within 30 calendar days of the payment date on the claim or the claim denial date. At a minimum, the dispute submission must include:

  • Sufficient information to identify the claim(s) in dispute
  • A statement of why you believe a claim adjustment is needed and the expected outcome of the claim adjustment
  • Pertinent documentation to support the adjustment

Incomplete requests will be returned with no action taken.

Claim disputes can be submitted to CareSource PASSE through the following methods:

  • Online: Provider Portal
  • Fax: 937-531-2398
  • Mail: CareSource PASSE
    Attn: Provider Appeals Department
    P.O. Box 2008
    Dayton, OH 45401

CareSource PASSE will render a decision on the dispute within 25 calendar days of receipt. If the decision is to uphold the original claim adjudication, you will receive a letter. If CareSource PASSE approves the dispute, payment will reflect on the Explanation of Payment (EOP). The submission of a claim dispute does not in any way impact or reduce the time to submit an appeal. All appeals must be filed within 60 days of an adverse decision/action, regardless of whether or not a claim dispute was filed.

Claim Appeals

If you do not agree with the decision of a processed claim, you will have 60 calendar days from the date the adverse action, denial of payment, remittance advice or initial review determination was mailed to you. Your appeal request should include all grounds for appeal and be accompanied by supporting documentation and an explanation of why you disagree with our decision.

If a claim appeal is not submitted in the required time frame, the claim appeal will not be considered, and the appeal will be dismissed. If your appeal is dismissed or denied, you will be notified in writing.

Peer-to-Peer Process

CareSource PASSE provides the opportunity for providers to discuss the Utilization Management (UM) medical necessity determination of a denial or decrease in level of care with CareSource PASSE’s Medical Director/Behavioral Health Medical Director or designee within five business days of the notification of the determination. The peer-to-peer process is independent of the appeal process and does not impact the timeframe a member and/or provider has to appeal.

To initiate the peer-to-peer process, please call CareSource PASSE’s Utilization Management team at 1-833-230-2168.

Clinical Appeals

If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from CareSource PASSE denying coverage, a provider or member can submit a pre-service or post-service clinical appeal.

  • Pre-Service Appeal: denial of an authorization for a service prior to being completed. You have 60 days from the date of the authorization denial to submit a pre-service appeal. The pre-service appeal must include the member’s written consent, which must be specific to the service requested. It is only valid for that appeal and must be signed/dated by the member. You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form (coming soon), available on our Forms webpage.
  • Post-Service Appeal: denial of an authorization for a service that has already been completed. You have 60 days from date of service, discharge or authorization denial to submit a post-service appeal. Member consent is not required for post service requests.

If you have not received an authorization denial from the CareSource PASSE Utilization Management department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal. Requests for retro-authorization must be submitted to CareSource PASSE’s Utilization Management department.

How to Appeal

Provider Portal: Log in to the Provider Portal with your username and password and access the Claim Appeals tab on the left.

In Writing: Use the Provider Claim Appeal Request Form (coming soon) and send back to CareSource PASSE by mail or fax.

  • Mail: CareSource PASSE Appeals Dept., P.O. Box 2008, Dayton, OH 45401
  • Fax: 937-531-2398

Please include the following information:

  • Member’s name and CareSource PASSE member ID number
  • The provider’s name and ID number
  • The code(s) and why the determination should be reconsidered
  • For a timely filing appeal, proof of original receipt of the appeal by fax or Electronic Data Information (EDI)
  • For a clinical edit denial, all the supporting clinical documentation as to the justification of reversing the determination

By Phone: Call Provider Services at 1-833-230-2100. If your appeal is submitted by phone, you must follow up the oral submission with a written, signed appeal within 10 calendar days.

Please note: If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You do not need to file an appeal. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Appeal Resolutions

Appeals may be reviewed by the CareSource PASSE grievance and appeals staff, medical directors, claim staff, provider relations staff and any department with reason to assist in resolving a complaint or appeal.

If the outcome of the review of the claim appeal is adverse to the provider, CareSource PASSE will provide a notice of adverse action. The notice of adverse action will state that you may request a state fair hearing.

If the appeal is approved, payment will show on your Explanation of Payment (EOP).

State Fair Hearings

CareSource PASSE requires exhaustion of the provider appeal process prior to requesting a state fair hearing. You have 90 days from the date of the appeal decision letter to request a state fair hearing.

If you have new information to be considered for your claim, you should submit a corrected claim. Corrected claims should not be submitted through the claim dispute process, the appeals process or the state fair hearing process.

A request for a state fair hearing must include the following information:

  • A clear expression by the provider that he or she wishes to present his or her case to a state fair officer
  • Identification of the action being appealed and the issues that will be addressed at the hearing
  • A specific statement of why the provider believes CareSource PASSE’s action is wrong
  • A statement of the relief sought

Providers should send all requests for state fair hearing to the Arkansas Department of Health at:

  • Mail: ADH Office of Medicaid Provider Appeals
    4815 West Markham St., Slot 31
    Little Rock, AR 72205
  • Phone: 501-683-6626
  • Fax: 501-661-2357

Updates & Announcements

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to our Updates & Announcements page for notifications of changes that may impact your appeal.

Contact Us

For any questions regarding CareSource PASSE’s processes, please contact Provider Services at 1-833-230-2100, Monday through Friday, 8 a.m. to 5 p.m. Central Time.