CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.
Prior Authorization Procedures
The Provider Portal is the preferred method to request prior authorizations for health care services. You get immediate approval or pend status, and can also check pending claim status. Email us at CiteAutoAssistance@caresource.com for portal login assistance.
Alternate methods include phone, fax or mail.
P.O. Box 1307
Dayton, OH 45401-1307
Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form (coming soon).
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:
All in-patient services require authorization. Please call 1-833-230-2176 to obtain authorization for emergency admissions. Outpatient emergency services do not require authorization.
Post Stabilization Services
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.
To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please call 844-679-7865 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.
Please call 1-833-230-2176 for any questions related to post-stabilization services.
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.