Appeals of Claim Denials or Adverse Decisions
If you do not agree with the decision of a processed claim, you will have 30 calendar days from the date the adverse action, denial of payment, remittance advice or initial review determination was mailed to you. The appeal request should include all grounds for appeal and be accompanied by supporting documentation and an explanation of why you disagree with our decision.
If the claim appeal is not submitted in the required time frame, the claim appeal will not be considered and the appeal will be denied. If the appeal is denied, providers will be notified in writing.
How to Appeal
Provider Portal: Log in to the Provider Portal with your username and password and access the Claim Appeals tab on the left.
In Writing: Use the Provider Claim Appeal Request Form. Please include the following and either mail to CareSource, Attn: Health Partner Appeals – Georgia, P.O. Box 2008, Dayton, OH 45402, or fax to 1-937-531-2398:
- Member’s name and CareSource member ID number
- The provider’s name and ID number
- The code(s) and why the determination should be reconsidered
- If you are submitting a timely filing appeal, proof of original receipt of the appeal by fax or Electronic Data Information (EDI) for reconsideration
- If the appeal is regarding a clinical edit denial, all supporting documentation as to the justification of reversing the determination
If you believe the claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim within (180) days of the date of service or discharge. You do not need to file an appeal.
In the event the outcome of the review of the claim appeal is adverse to the provider, CareSource will provide a notice of adverse action. The notice of adverse action will state that the provider may request an administrative law hearing in accordance with O.C.G.A. § 49-4-153, O.C.G.A. § 50-13-13 and O.C.G.A. § 50-13-15.
If the appeal is approved, payment will show on the provider’s Explanation of Payment (EOP).
Appeals may be reviewed by the CareSource grievance staff, medical directors, claim staff, provider relations staff and any department that may have reason to assist in resolving a complaint or appeal.
Exhaustion of CareSource Internal Appeals Process
Providers who have exhausted CareSource’s internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal have the option to either:
- Pursue the administrative appeals process described in O.C.G.A. § 49-4-153(e), or
- Select binding arbitration by a private arbitrator who is certified by a nationally-recognized association that provides training and certification in alternative dispute resolution as described in O.C.G.A. 33-21A-7.
If CareSource and the provider are not able to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this code shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 calendar days of being selected, unless CareSource and the provider mutually agree to extend this deadline. All costs for arbitration, not including attorney’s fees, shall be shared equally by the parties.
CareSource requires exhaustion of the internal provider complaint/appeal process prior to requesting an administrative law hearing.
A request for an administrative law hearing must include the following information:
- A clear expression by the provider that he/she wishes to present his/her case to an administrative law judge;
- Identification of the action being appealed and the issues that will be addressed at the hearing;
- A specific statement of why the provider believes CareSource’s action is wrong; and
- A statement of the relief sought.
The Department of Community Health has delegated its authority to receive administrative law hearing requests to CareSource. Providers should send all requests for administrative law hearings to CareSource, Attn: Administrative Law Hearing Request – Georgia, P.O. Box 2008, Dayton, OH 45402, or by fax to 866-317-2157.
An administrative law hearing must be requested by the provider no later than 15 business days after the provider receives CareSource’s notice of adverse action.
For any questions regarding CareSource’s complaint and appeal processes, please contact Provider Services at 1-855-202-1058, Monday through Friday, 7 a.m. to 7 p.m. Eastern Standard Time (EST).