Provider Disputes or Appeals
Definitions
CareSource PASSE™ provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:
Claim Appeals
A claim appeal is a 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 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. 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 may 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 or date of payment to submit an appeal. 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 65 days from the date of the authorization denial to submit a pre-service appeal.
- Post-Service Appeal: denial of an authorization for a service that has already been completed. You have 65 days from date of denial or date of payment 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. Request for retro-authorization submitted to the appeals department may result in delay or dismissal of your request.
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.