Prior Authorization

CareSource PASSE™ evaluates prior authorization requests based on medical necessity 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 PASSE should be authorized before the service is delivered. CareSource PASSE is not able to pay claims for services in which prior authorization is required but not obtained by the provider.

Prior Authorization Procedures

The Provider Portal is the preferred and faster method to request prior authorization for health care services. You can receive immediate approval and review the status of an authorization.

Providers can obtain prior authorization for emergency admissions via the Provider Portal, fax, email or by calling Provider Services at 1-833-230-2100.

  • Fax: 844-676-0370
  • Mail: CareSource PASSE
    Attn: Utilization Management Dept.
    P.O. Box 1598
    Dayton, OH 45401-1598

Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form (coming soon).

Home and Community Based Services (HCBS)/Waiver providers should submit the HCBS/Waiver Provider Prior Authorization Request Form (coming soon).

Nonparticipating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

Emergency Services

All inpatient services require prior authorization. Please call 1-833-230-2100 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.

Post Stabilization Services

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.

To request prior authorization for observation services as a non-participating provider or to request authorization for an inpatient admission please call 1-833-230-2100. During regular business hours, your call will be answered by our Utilization Management department. If calling after regular business hours, the call will be answered by CareSource24®, our Nurse Advice Line.

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.

Pharmacy Prior Authorization

Some drugs may require prior authorization before they will be covered. Please refer to the Pharmacy page to review these requirements.

For drugs processed through Express Scripts, please refer to the Formulary or Preferred Drug List (PDL) on the Drug Formulary page. For drugs through the medical benefit, please refer to the Procedure Lookup Tool and Authorization Requirements for Medications under the Medical Benefit (coming soon).