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.