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 Appeals

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 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. 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 a 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.

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 90 calendar days of the date of denial or date of payment.

  • 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 2008
    Dayton, OH 45401

CareSource will render a decision within 30 calendar days of receipt. If the dispute is approved, the payment will appear on your Explanation of Payment (EOP). If the decision is to uphold the original claim adjudication, we will send you a letter and you may appeal the decision. Appeals must be submitted within 365 calendar days of date of service or date of discharge.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 365 calendar days from the date of service or date of discharge, unless otherwise specified in your contract, to submit an appeal. We encourage you to utilize the provider claim dispute process outlined above prior to appealing.

If you do not submit an appeal in the required time frame, CareSource will not reconsider the claim, and the appeal will be dismissed. You will be notified in writing if your appeal is dismissed or denied. If your appeal is approved, your payment will appear on your Explanation of Payment (EOP). A determination will be made on the appeal within 60 calendar days.

Please note: If you believe a claim processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file an 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.

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 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.

  • Pre-Service Appeal: denial of an authorization for a service prior to being completed. You have 180 days from the date of the authorization denial to submit a pre-service appeal. The pre-service appeal must be accompanied with a member’s written consent, must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member. You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form, available on our Forms webpage.
  • Post-Service Appeal: denial of an authorization for a service that has already been completed. You have 180 days from date of service, discharge 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 Utilization Management Department for a service that requires a prior authorization, you must submit a retro-authorization request to the CareSource Utilization Management department prior to filing a clinical appeal.

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 you file an appeal on behalf of a member or for pre-service issues, you must be appointed by the member as their authorized representative. This appointment must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. Please note: You can use the NavigateInternal Appeal Request form and the NavigateAppointment of Representative form to request the appeal and record this consent.

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 1-855-202-1058, Monday through Friday, 7 am – 7 pm Eastern Standard Time (EST).