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 a formal review of the processing of a claim by CareSource (excluding denials based on medical necessity) and is typically related to underpayment or overpayment of a claim. You can submit a claim payment dispute when you disagree with payment of the claim.
  • Claim Appeal – 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 Appeal – 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.

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. However, if you submit a request for review of an overpaid claim through the claim payment dispute process, we will review it. 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 will 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.

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 NavigateConsent 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.

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 NavigateProvider 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

Please note: If you believe a 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. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Appeal Resolutions

If the outcome of the claim appeal review is adverse to a 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 an appeal is approved, the payment will appear 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 with 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/dispute process prior to requesting an administrative law hearing.

Administrative 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 through one of the following methods:

  • Provider Portal
  • Fax: 937-531-2398
  • Mail: CareSource
    Attn: Administrative Law Hearing Request – Georgia
    P.O. Box 2008, Dayton, OH 45402

A provider must request an administrative law hearing no later than 30 calendar days after the date on CareSource’s notice of adverse action.

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 a.m. to 7 p.m. Eastern Standard Time (EST).