Provider Disputes and Appeals

Provider 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 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 by clicking the Claims link on the menu to the left or the Provider Manual for further information related to claims submission.

Process for Claim Payment Disputes

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

Claim payment disputes must be submitted in writing.

The dispute must be submitted within ninety (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. Payments 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 thirty (30) calendar days of receipt. If the dispute is approved, payment will reflect on the provider’s Explanation of Payment (EOP). If the decision is to uphold the original claim adjudication, providers may appeal. Appeals must be submitted within 365 calendar days of date of service or date of discharge.

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.

For pre-service appeals submitted with written member consent, the standard appeal decision time frame is 30 calendar days from the date of receipt by CareSource.

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 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 payment dispute process prior to appealing. Please reference the claim payments disputes information here.

If the appeal is not submitted in the required time frame, the claim will not be reconsidered and the appeal will be dismissed. Providers will be notified in writing if the appeal is dismissed or denied. If the appeal is approved, payment will show on the 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 by clicking the Claims link on the menu to the left or the Provider Manual for further information related to claims submissions.

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, the provider or the member can submit a clinical appeal within 180 calendar days from the date of the adverse benefit determination. Providers must have a member’s written consent to file an appeal on behalf of a member and to appeal pre-service issues. The Appointment of Representative form must be completed and submitted with the appeal. The consent must be specific to the service being appealed, is only valid for that appeal and must be signed by the member.

How to Submit Appeals

You can submit claim 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 provider must be appointed by the member as their authorized representative which 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 Appointment of Representative form to request the appeal and record this consent.)