Find answers below to common questions about how to work with CareSource.
Georgia Pathways to Coverage
Review the FAQs document to answer any questions you may have about the program.
How do I obtain prior authorization?
- To streamline operations for our providers, CareSource will work with the Department of Community Health’s (DCH’s) central prior authorization portal for communicating prior authorization and precertification requests and their disposition.
How do I request a retrospective review?
Health partners have 180 days from the date of service, date of discharge or 90 days from another carrier’s denial on an Explanation of Payment (EOP), whichever is later, to request a retrospective review for medical necessity. The retrospective review request must include a copy of the other carrier’s EOP. All requests for services will be reviewed for timeliness and medical necessity.
Health partners can request a retrospective review by contacting the Medical Management department at 1–855-202-1058 or by faxing the request to 844-676-0370. Clinical information supporting the request for services must accompany the request.
Timely Filing Requirements
What are the requirements for timely filing?
- All CareSource claims that are clean with correct coordination of benefits will now be accepted 180 days from the date of service.
- Claim appeals will be accepted 30 days from the date of the adverse action, denial of payment, remittance advice, or initial review determination was mailed.
How is the filing period counted?
- Days will be counted from the date of service or the discharge date, whichever is greater.
How much time does a health partner have to file if he/she makes an error when submitting a claim?
- Health partners have 180 days from the date of service to submit a corrected claim. Identify the claim as “Corrected” when resubmitting to CareSource.
Who do health partners contact with questions?
- Health partners should contact Health Partner Services at 1-855-202-1058.
Is there a difference in the information I receive if I sign up as a provider or as a group?
- There is no difference in the information you will receive.
How can I reset my password if I don’t remember it?
- The primary user cannot reset his or her password. For assistance resetting your password, please contact Health Partner Services at 1-855-202-1058.
How can I add additional users?
- After logging into the Provider Portal, the primary user can add additional users through the “manage users” tab in the left navigation menu.
How do I check member eligibility?
It is important to verify member eligibility before providing services. Patients must be eligible CareSource® members at the time of service in order for services to be covered.
CareSource offers several ways to check member eligibility including by phone or here on our website.
Can I see a member if my name is not on the member’s card?
- Yes! Any participating primary care provider (PCP) may see eligible CareSource members. PCPs are responsible for verifying member eligibility before providing any services. Please log on to the Provider Portal to confirm member eligibility. Please note, eligibility does not guarantee payment of the claim.
How do I file an appeal?
What if a health partner appeals and the claim is still denied?
- Appeals that have gone through the formal appeal process are deemed to be final. However, health partners may have administrative law hearing (state fair hearing) rights.
How do I submit a claim?
CareSource accepts paper and electronic claims. We encourage you to submit electronic claims through the Provider Portal for quicker processing. Please see the Claims page for more information.
Health partners have 180 days from the date of service or discharge to submit claims.
How can I optimize my claim payment timeframe?
Claims submitted electronically are typically received and processed more quickly than paper claims. Health partners may submit claims electronically through the CareSource Provider Portal or through Electronic Data Interchange (EDI) clearinghouses specified by CareSource. For paper claim submissions, we require the most current form versions as designated by the Centers for Medicare & Medicaid Services (CMS), National Uniform Billing Committee (NUBC) and the American Dental Association (ADA). We cannot accept handwritten claims or superbills.
Tips for submitting paper claims:
- Use only original claim forms. Do not submit claims that have been photocopied or faxed.
- Fonts should be 10-14 point (capital letters preferred) with printing in black ink.
- Do not use liquid correction fluid, stickers, labels or rubber stamps.
- Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form.
- Do not include handwritten information on the form.
- We recommend including your 12-digit CareSource provider ID, which allows for fastest paper claim processing. Your provider ID may be found on your Welcome letter.
- In general, using clean claim forms with legible print will allow for more efficient processing.
How soon will I know if my claim was paid?
- All clean claims will be processed within 15 business days of receipt. Payment notification is made via Explanation of Payment (EOP).
How do I check pended claims?
- Checking claim statuses is one of many services available to our providers 24 hours a day through our secure Provider Portal. The pended claims report is another resource for claim status and it is sent biweekly.
Can I ever bill my CareSource patients?
- Health partners may not bill members for any covered services, with the exception of copayments. However, if the member cannot afford their copayment, you must still render services to the member and cannot turn away the member. Please visit the Member Billing Policy page for more information.
Coordination of Benefits
How do I determine which plan is the primary payer?
- Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare Managed Care Plans.
How do I know if a member has other coverage?
It is the responsibility of the health partner to verify and obtain all COB information at time of service.
There are two ways to verify:
Online: Visit the Provider Portal to view the COB information that CareSource has on file for the member.
By phone: Call 1-855-202-1058 and follow the menu prompts.
How do I submit Coordination of Benefits?
Coordination of Benefits (COB) claims can be submitted by mail or electronically:
- COB claims should be submitted by mail with the Explanation of Benefits and mailed to CareSource, Attn: Claims Department, P.O. Box 803, Dayton, OH 45401.
- COB claims can be submitted on the Provider Portal and accepts attachment with the claim.
- For electronic COB claims submission, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information.
Can I submit Coordination of Benefits claims electronically?
- Yes! CareSource can accept Coordination of Benefits (COB) claims electronically. CareSource accepts both professional claims (CMS-1500) and hospital/facility claims (UB-04) electronically. CareSource’s dental claims are managed through SkyGen, which accepts electronic dental claims through clearinghouses and the SkyGen Portal. We recommend that dental health partners submit claims using ADA forms.
How do I submit Coordination of Benefits claims electronically?
- When submitting Coordination of Benefits (COB) claims electronically, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information. For professional claims (CMS-1500), COB information should be sent at the line level. For hospital/facility claims (UB-04), COB information should be sent at the claim level. In addition to the required COB information, you must send other carrier paid amounts and all claim/line level adjustment group codes, reason codes, remark codes and payment amounts.
What Coordination of Benefits information must be submitted?
For secondary electronic (EDI) professional and institutional claims, the following Coordination of Benefits (COB) information must be submitted:
- Primary Payer Paid Amount: Submit the primary/COB paid amount for each claim reported on the 835 payment or as identified on the explanation of payment (EOP).
- Adjustment Group Code: Submit other payer claim adjustment group codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered service group codes.
- Adjustment Reason Code: Submit other payer claim adjustment reason codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services or HIPAA codes.
- Adjustment Amount: Submit other payer claim adjustment amounts as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services payments.
Where do I include Coordination of Benefits information?
For secondary professional or institutional claims to be paid electronically, all Coordination of Benefits (COB) information must be submitted in the applicable loops and segments. Loops include:
- Loop ID – 2320: Other Subscriber Information
- Loop ID – 2330A: Other Subscriber Name
- Loop ID – 2330B: Other Payer Name
- Loop ID – 2330: Other Provider Information
- Loop ID – 2430: Line Adjudication Information (for professional claims)
If I receive a denial for not supplying Coordination of Benefits, what do I need to do?
Submit a copy of the Explanation of Benefits (EOB) by fax, mail or through the Provider Portal:
- By fax: 937-396-3138
- By mail: CareSource, P.O. Box 803, Dayton, OH 45401
- Through the Provider Portal: submit the claims as attachments
You can also submit the claim and EOB electronically. Please refer to your clearinghouse, trading partner or billing administrator to complete this process.
What if I receive a denial for COB and the member’s primary coverage is no longer effective?
What if the Provider Portal is missing information, such as the group number or member’s date of birth?
- Check the carrier’s website or call the carrier directly to obtain the information. We encourage all health partners to verify the patient’s insurance coverage at the time of service.
What are the timely filing guidelines for Coordination of Benefits?
- If a member has other insurance and CareSource is secondary, then the health partner must submit for secondary payment within 90 calendar days of date on the primary carrier’s EOB, but not more than 12 months from the date of service or discharge. Claims that are filed timely with a primary carrier, but did not generate a response from the carrier, despite all reasonable actions taken, must be filed not more than 12 months from the date of service or discharge indicating no response was received. In no event, regardless of cause or circumstance, shall the member be responsible or liable for a claim submitted to CareSource after the expiration of the timely filing deadline.
If I receive a denial showing the member has other coverage, how can I get the other coverage information?
How does COB work when CareSource is a secondary payer for obstetrician deliveries?
CareSource will deny all prenatal office visits when the explanation for COB information needed has not been provided. Once the primary EOB is received, CareSource will verify if the prenatal visits are a part of the primary payer’s global reimbursement. If they are, CareSource will make no payment until a delivery charge is received. If the prenatal visits are excluded by the primary payer (e.g., maternity benefits not covered by the plan), CareSource will process the claim as if CareSource was the primary payer.
Once the delivery charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary payer’s payment from the Medicaid allowable amount (the benefit allowance for all visits and the delivery charge) and will pay any remaining CareSource allowable payment.
Global Obstetrical Codes are Not Recognized
If the first claim that CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill, within 90 days of the denial or 180 days from the date of service, using the delivery only CPT codes since CareSource does not recognize global obstetrical codes for claims processing.
Once the delivery charge is received, CareSource will determine the Medicaid allowed amount and then subtract the primary insurance paid amount. CareSource will pay any remaining liability up to the Medicaid allowed amount. CareSource will not pay more than the CareSource normal benefit when no other coverage exists.
For OB delivery claims, CareSource will not require the primary payer’s EOB charges to match the charges on the claims submitted to CareSource.
What if the primary payer denies for non-cooperative parent/procedural reasons?
CareSource will require a copy of the primary carrier’s Explanation of Payment (EOP) denial in order to process the claim as primary when claims are denied by the primary carrier for the following reasons:
Member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire)
Procedural denial reasons (e.g., timely filing, prior authorization, referral from primary care provider)
When will CareSource automatically adjust a denied COB claim?
CareSource will automatically adjust a claim that originally denied for COB when the following criteria are met:
Primary insurance has been updated retroactively to show coverage terminated AND
The claim was denied for COB within 90 days of receiving the updated information that the primary coverage has been terminated
Claim for date of service 6/15/16 was denied on 7/10/16 due to the member having primary coverage effective 1/1/16.
CareSource received notification on 9/1/16 that the other coverage terminated on 5/31/16.
Since the claim was originally processed within the 90 day period of receiving the notification that the primary coverage was terminated, CareSource would automatically adjust the claim.
CareSource will NOT automatically adjust a denied COB claim if the updated coverage was received after 90 days from the denial for COB. The health partner must submit for secondary payment within 90 calendar days of date on the primary carrier’s EOB, but not more than 12 months from the date of service or discharge.
What is CareSource?
CareSource is a nonprofit managed health care organization that serves consumers of Medicaid, Marketplace and Medicare; including families with low incomes, children, pregnant women and people who are aged, blind or have disabilities.
We contract with the Georgia Department of Community Health to provide services. Our focus is on prevention and partnering with local health care providers to offer the services our members need to remain healthy.
What are the advantages of participating with CareSource?
CareSource’s foundation is our strong partnership with our contracted health partners. Because health partners are so integral to the delivery of services, CareSource offers them a wide array of services and benefits, including:
- Prompt claims payment
- Claims call center
- Paperless referrals and low-hassle medical management
- Web-based transactions and electronic claims submission
- Secure Provider Portal available 24/7 where health partners can perform a variety of functions, including checking eligibility and claim status, submitting prior authorizations and more
- Provider relations staff
- Commitment to service
- Member support services
How can I become a participating health partner?
How can I reach CareSource?
- Call Health Partner Services at 1-855-202-1058, Monday through Friday, 7 a.m. to 7 p.m. Eastern Time (ET), except holidays. Please tell Katie, our interactive voice response system, how to best assist you.
How do I make a referral?
CareSource uses a paperless referral. To make a referral, primary care providers (PCPs) simply:
- Document the referral in the member’s medical chart. Please note the number of visits or length of time for each referral.
- Tell the member how to get the service.
- Notify the specialist of the referral.
A specialist documents the referral in the member’s chart as well. Referral forms are not required.
For more information, please visit the Referrals and Prior Authorizations section of the provider manual.
What benefits does CareSource offer its members?
- CareSource offers our members many extra benefits and support services, such as a 24/7 nurse advice line, care management, programs to encourage members to keep prenatal and postpartum appointments, and more. Visit our Covered Services grid (coming soon) to see benefit limits on select services.