Provider Disputes and Appeals

Definitions

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

  • Claim Dispute – A dispute is the first formal review of the processing of a claim by CareSource (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 Appeal – 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. Please refer to your denial letter to exercise your available peer-to-peer rights. CareSource 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 Appeal – 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 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 should not file a dispute or appeal. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Process for Claim Disputes

Medicare providers who are in CareSource’s network and are participating for CareSource members must use the dispute process for any claim denials. Appeal rights do not exist for participating Medicare providers.

If you believe your claim was denied incorrectly or underpaid, you can submit a claim dispute.

Claim disputes must be submitted in writing. The dispute must be submitted within 60 calendar days of the date of denial or date of payment.

At a minimum, the dispute must include:

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

Incomplete requests will be returned with no action taken. Claim disputes can be submitted to CareSource through the following methods:

  • Provider Portal
  • Fax: 937-531-2398
  • Mail: CareSource
    Attn: Provider Appeals Department
    P.O. Box 1947
    Dayton, OH 45401-1947

CareSource will render a decision within thirty calendar days of receipt. If the decision is to uphold the original claim adjudication, if you are a non-participating provider, you may appeal the decision. Appeals must be submitted within 60 days of the date of the denial.

Provider Appeals

Providers may request the following types of appeals:

  • Claim appeals: Submit a claim appeal to request reconsideration of a claim denial.
  • Clinical appeals: Submit a clinical appeal to request reconsideration of a medical necessity decision.

All appeal requests and associated information are reviewed by clinicians not previously involved with the case.

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.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 60 days to submit an appeal from initial adverse decision.

If the appeal is not submitted in the required time frame, with a statement of Good Cause, the claim will not be reconsidered, and the appeal will be dismissed. You will receive notification in writing if the appeal is denied. If your appeal is approved, your payment will appear on the Explanation of Payment (EOP).

Please note: If your issue is not related to a lack of authorization, please utilize the payment dispute process outlined above as your first method to resolve the issue.

Peer-to-Peer Process

CareSource 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’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’s Utilization Management team at 1-833-230-2168.

Clinical Appeals

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

After receiving a letter from CareSource® denying service 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, when not submitted by a physician or physician’s representative, must be accompanied by a valid Authorization of Representative (AOR) form. The AOR form is available on our Forms webpage.
  • Post-Service Appeal: denial of an authorization for a service that has already been completed. You have days from date of service, discharge or authorization denial to submit a post-service appeal.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must not submit a retro-authorization request prior to filing a clinical appeal, your issue is now considered a claim appeal and should be submitted as such.

The first appeal requested is called a Level 1 appeal. In this appeal, the coverage decision is reviewed to ensure we followed all the rules properly.

Providers can request a coverage decision or Level 1 appeal on a member’s behalf. If the appeal is denied at Level 1, it will be automatically forwarded to Level 2. Level 2 appeals are conducted by independent organizations not connected to us. For a provider to request any appeal after Level 2, the member must appoint the provider as his or her representative. NavigateLearn more about Appointing a Representative.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). Details of all levels can be found in the provider manual (coming soon).

How to Submit Appeals

You can submit appeals through our Provider Portal or using the NavigateProvider Appeal Form. The Provider Portal is the most efficient method of submitting appeals.

Include the following required documentation:

  • Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested.
  • Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes
  • If the service has already been provided, a copy of the original remittance advice and/or the denied claim
  • If filing an appeal on behalf of a member or for pre-service issues, the valid Authorization of Representative form must accompany the appeal.

Expediting Clinical Appeals

If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal.

Call us at 1-833-230-2176 to request an expedited clinical appeal.

Notification of Resolution

CareSource will decide whether to expedite an appeal within 24 hours. We will make reasonable efforts to provide prompt verbal notification to the member of the decision to expedite or not expedite the appeal; the attempt will be made by phone. If the member is in a facility, their appeal must go through the Quality Improvement Organization (QIO), Livanta. The provider or facility will be notified on the same business day of the decision.

Expedited appeals will be resolved and verbal notification will be made within 72 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. CareSource will send written notification to both the provider and the member on the same business day of the decision.

Denied Expedited Appeals

If CareSource decides not to expedite the clinical appeal, we will send written notification within two calendar days of receipt of the appeal to both the member and the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. The appeal will be resolved within 30 calendar days from the date the appeal was received and follow the standard CareSource appeal process.

Extending an Appeal

Members may verbally request that CareSource extend the time frame to resolve any medically necessity appeal request up to 14 days. CareSource may also request an extension.

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’s processes, please contact Provider Services at 1-833-230-2176, Monday through Friday, 8 a.m. to 6 p.m. Eastern Standard Time (EST).