Provider Appeals

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.

Process for Claim Payment Disputes:

If you believe the claim was under paid or over paid, you can submit a request for adjustment through the claim payment dispute process. You do not need to submit an appeal for this type of review. Request for review of a claim denial should be submitted as an appeal. For more information about appeals, review the Appeals of Claim Denials and Adverse Decisions section on this page.

Claim payment disputes must be submitted in writing within three (3) 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 (10) calendar days of the date on the letter notifying you of the incomplete request.

Payments disputes can be submitted to CareSource through the following methods:

CareSource will render a Payment Dispute decision letter within fifteen (15) calendar days of receipt. If the decision is to uphold the original claim adjudication, the provider will receive a letter which will include the right to request an Administrative Law Hearing.

Appeals of Claim Denials

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 dismissed. If the appeal is dismissed or denied, providers will be notified in writing.

Clinical Appeals

After receiving a letter from CareSource denying a pre-service coverage determination, the provider or the member can submit a clinical appeal within 60 calendar days of the notice of 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 consent must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form, available on our Forms webpage.

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.

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 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

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.

Appeal Resolutions

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/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, Attn: Administrative Law Hearing Request – Georgia, P.O. Box 2008, Dayton, OH 45402, the Provider Portal or by fax to 937-531-2398.

An administrative law hearing must be requested by the provider no later than 30 business days after the provider receives CareSource’s notice of adverse action.

Contact Us

For any questions regarding CareSource’s complaint, dispute 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).