Provider Disputes or Appeals

Definitions

CareSource provides several opportunities for you to request review of claim or authorization denials. Provider Services Call Center specialists are available to help review your claims and advise of next steps at 1-855-202-1058. Actions available after a denial include:

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.

Process for Claim Disputes

If you believe the claim was under paid or over-paid, you can submit a request for adjustment through the claim dispute process. Please note, the preferred method for adjustment requests involving overpaid claims is submission of a recovery request on the Provider Portal. You do not need to submit an appeal for this type of review. A request for review of a claim denial should be submitted as an appeal.

Claim disputes must be submitted in writing within three months of the payment date on the claim. At a minimum, the dispute submission must include:

• Sufficient information to identify the claim(s) in dispute
• A statement of why you believe a claim adjustment is needed and the expected outcome of the claim adjustment
• Pertinent documentation to support the adjustment

Incomplete requests may be returned with no action taken. The request must be resubmitted with all necessary information within ten calendar days of the date on the letter notifying you of the incomplete request.

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 claim dispute decision within 15 calendar days of receipt. If the decision is to uphold the original claim adjudication, you will receive a letter which will include information on your right to request an administrative law hearing. If the claim dispute is approved, you will receive a new EOP.

Claim Appeals

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. Your 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 a claim appeal is not submitted in the required time frame, the claim appeal will not be considered, and the appeal will be dismissed. If your appeal is dismissed or denied, you will be notified in writing. For claim denials that are missing documentation, you should upload the necessary documentation on the Provider Portal for the claim. 

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 60 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 Navigate 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 30 days from the date of the 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. Requests for retro-authorization submitted through the appeals process cannot be accepted and will be dismissed.