Provider Disputes or Appeals
Definitions
We provide 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 written request by an out-of-network provider to review the denial or payment of a claim due to processing errors. For out-of-network providers, please refer to the Non-Participating Provider Appeals and Disputes.
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 by participating providers. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial. CareSource pays non-contracted providers, as Medicare would have paid for the same service. If your disagreement is limited to the amounts a non-contracted provider could collect if the beneficiary were enrolled in original Medicare pursuant to § 422.214(a)(l), you should use the plan’s internal payment dispute process and submit your claim payment dispute to:
CareSource
Attn: Provider Disputes
P.O. Box 1947
Dayton, OH 45401-1947
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 Utilization Management department. For more information about requirements for pre-service appeals and post-service disputes, view the Clinical Appeals/Disputes 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.
Please note: All Non-participating providers should submit their claim issues as Claim Appeals and not as a Payment Dispute.
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 (Preferred Method)
- Fax: 937-531-2398
- Mail: CareSource
Attn: Provider Appeals
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 calendar days from the receipt of the denial, which is presumed to be five days from the date on the notice.
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.
Claim Appeals
If you are a non-participating provider, and if you do not agree with a denial on a processed claim, you have 60 calendar days from the date of the receipt of the initial adverse decision, which is presumed to be five days from the date on the notice.
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.
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 coverage, a provider or member can submit a pre-service or post-service clinical appeal. Clinical appeals are reviewed by nurses and physicians not involved in any prior review. They are also reviewed by practitioners with expertise and knowledge appropriate to the item, service, or drug being requested.
Pre-service reconsiderations submitted by providers are processed under the enrollee appeal pathway.
Filing Deadline
- A reconsideration must be requested within 60 calendar days from the date on the denial notice.
- Receipt of the notice is presumed to be 5 calendar days after the date on the notice, unless there is evidence to the contrary.
- Good cause for late filing may be considered.
Pre-Service Reconsiderations
For services not yet rendered:
- Standard reconsiderations are resolved within 30 calendar days of receipt.
- The timeframe may be extended by up to 14 calendar days if requested or if additional information is needed and the delay is in the enrollee’s best interest.
- Providers submitting a pre-service reconsideration are not required to submit an Appointment of Representative (AOR) at Level 1.
Post-Service Reconsiderations
For services already rendered:
- Standard reconsiderations are resolved within 60 calendar days of receipt.
- A non-contracted provider must include a valid waiver of liability (WOL) to request a post-service reconsideration.
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. Learn 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.