Utilization Management

The CareSource Utilization Management (UM) team will review the health care services you get, based on established criteria or guidelines. We review to make sure it is the best care for your needs. If you have questions about how your care is reviewed, you can contact the UM team through Member Services and the representative will connect you. When calling, please keep the following in mind:

  • UM is open for calls Monday – Friday from 8 a.m. to 5 p.m. Eastern Time (ET).
  • You may leave a message about UM issues after normal business hours.
  • You may also use the website to contact UM during and after normal business hours.
  • If you are contacted by UM staff members, they will identify themselves with their names, titles and the organization name (CareSource) when they call about UM issues.
  • Staff are available to accept collect calls regarding UM issues.
  • Staff are accessible to callers who have questions about the UM process.
  • UM is available to conduct utilization review during normal business hours and extended hours on Monday, Friday, and federal holidays until 6 p.m.

You can call us anytime about UM for prior authorization requests. We also give help to members that speak a language other than English so they can talk about UM issues or concerns. Just call Member Services at the number below.

Any decisions we make with your health partners about the medical necessity of your health care are based only on how the health setting or service will affect your care. CareSource does not reward health partners or our own staff for turning down coverage or services. We do not offer financial incentives to our staff in order to urge them to make decisions that result in under-utilization.

New Care Approvals

CareSource may decide that a new development not currently covered by Medicaid will be a covered benefit. This includes newly developed:

  • Health care services
  • Medical devices
  • Therapies
  • Treatment options

Coverage is based on:

  • Updated Medicaid and Medicare rules
  • External technology assessment guidelines
  • Food and Drug Administration (FDA) approval
  • Medical literature recommendations

Member Services: 1-844-607-2829 (TTY: 1-800-743-3333), 8 a.m. to 8 p.m., Monday – Friday Eastern Time.