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. The standard decision time frame for post-service provider appeals is 60 calendar days.

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 180 calendar days from the date of the denial, 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 below.

If the appeal is not submitted in the required time frame, the claim will not be reconsidered and the appeal will be denied. Providers will be notified in writing if the appeal is denied. If the appeal is approved, payment will show on the Explanation of Payment (EOP).

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. Providers have 365 days from the date of service or discharge to submit a corrected claim.

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 service, denial or discharge. Providers must have a member’s written consent to file an appeal on behalf of a member and to appeal pre-service issues. The consent must be specific to the service being appealed, is only valid for that appeal and must be signed by the member.

Please be aware that you have Peer to Peer rights that 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. Please refer to your denial letter to exercise your available Peer to Peer rights with CareSource.

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 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 to record this consent.)

Claim Payment 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.

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.
  • 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. 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 decision is to uphold the original claim adjudication, providers may appeal. Appeals must be submitted within 180 days of the date of the denial.