Find answers below to common questions about how to work with CareSource.
How do I obtain prior authorization?
Health partners can obtain prior authorization for health care services by contacting the CareSource Medical Management department by phone, fax, mail, online Provider Portal or email. Requests can be submitted on the Prior Authorization Request Form.
Submit a prior authorization request:
Is authorization needed for referrals to specialists?
- A referral is required for CareSource members to be evaluated or treated by most participating specialists, except where a self-referral is allowed. A prior authorization is needed to refer a member to a nonparticipating health partner. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the primary medical provider (PMP). Please see the CareSource health partner manual for more details.
Is authorization required for an observation?
- Authorization for an observation stay in a participating facility is not required. An observation in a non-participating facility does require an authorization and must be reported to the Medical Management department.
Does CareSource require authorization if the member has primary insurance?
Prior authorization is not required when CareSource is the secondary payer for medical services.
Prior authorization is required for any dental request listed on the prior authorization list when CareSource is the secondary payer.
How do I request a retrospective review?
Health partners have 180 days from the date of service, date of discharge or 90 days from another carrier’s denial on an Explanation of Payment (EOP), whichever is later, to request a retrospective review for medical necessity. The retrospective review request must include a copy of the other carrier’s EOP. All requests for services will be reviewed for timeliness and medical necessity.
Health partners can request a retrospective review by contacting the Medical Management department at 1-888-880-4889 or by faxing the request to 1-844-432-8924. Clinical information supporting the request for services must accompany the request.
Timely Filing Requirements
What are the requirements for timely filing?
- Claim disputes must be submitted within 60 days from the claim Explanation of Payment (EOP).
- Upon resolution of the claim dispute, providers have 60 days to submit a claim appeal.
- Clinical appeals must be submitted within 60 days of the date of service.
- Claims for in-network providers must be submitted within 90 calendar days from the date of services or discharge. Claims for out of network providers must be submitted within f180 calendar days from the date of service or discharge.
How is the filing period counted?
- Days will be counted from the date of service or the discharge date, whichever is greater.
How much time does a health partner have to file if he/she makes an error when submitting a claim?
- Health partners have 90 days from the date of service to submit a corrected claim. Identify the claim as “Corrected” when resubmitting to CareSource.
Who do health partners contact with questions?
Is there a difference in the information I receive if I sign up as a provider or as a group?
- There is no difference in the information you will receive.
How can I reset my password if I don’t remember it?
- The primary user cannot reset his or her password. For assistance resetting your password, please contact Health Partner Services at 1-844-607-2831.
How can I add additional users?
- After logging into the Provider Portal, the primary user can add additional users through the “manage users” tab in the left navigation menu.
How do I check member eligibility?
It is important to verify member eligibility before providing services. Patients must be eligible CareSource members at the time of service in order for services to be covered.
CareSource offers several ways to check member eligibility including by phone or here on our website.
Why can’t I check future eligibility of a member?
- All Medicaid recipients receive eligibility from the state on a month-to-month basis. Because of this, CareSource cannot be provided member eligibility for the upcoming months.
Can I see a member if I am not his or her assigned PMP?
- Yes! Any participating primary medical provider (PMP) may see eligible CareSource members. PMPs are responsible for verifying member eligibility before providing any services. Please log on to the Provider Portal to confirm member eligibility. Please note, eligibility does not guarantee payment of the claim.
How do I file an appeal?
What if a health partner appeals and the claim is still denied?
- Appeals that have gone through the formal appeal process are deemed to be final.
What if CareSource makes an error in how the claim was paid?
Providers have 365 days from the date of service to notify CareSource. The 365 day timeframe should give ample time to cite references and documentation regarding the error.
Please see the Grievances & Appeals page for more information.
How do I submit a claim?
CareSource accepts paper and electronic claims. We encourage you to submit electronic claims for quicker processing. Please see the Claims page for more information.
Indiana Medicaid health partners have 90 days from the date of service to submit claims.
How can I optimize my claim payment timeframe?
Claims submitted electronically are typically received and processed more quickly than paper claims. Health partners may submit claims electronically through the CareSource Provider Portal or through electronic data interchange (EDI) clearinghouses specified by CareSource. For paper claim submissions, we require the most current form versions as designated by the Centers for Medicare & Medicaid Services (CMS), National Uniform Billing Committee (NUBC) and the American Dental Association (ADA). We cannot accept handwritten claims or superbills.
Tips for Submitting Paper Claims:
- Use only original claim forms. Do not submit claims that have been photocopied or faxed.
- Fonts should be 10-14 point (capital letters preferred) with printing in black ink.
- Do not use liquid correction fluid, stickers, labels or rubber stamps.
- Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form.
- Do not include handwritten information on the form.
- We recommend including your 12 digit CareSource provider ID, which allows for fastest paper claim processing. Your provider ID may be found on your Welcome letter.
- In general, using clean claim forms with legible print will allow for more efficient processing.
How soon will I know if my claim was paid?
The majority of clean claims are processed within 30 days; we strive to process all claims received within 90 days. Payment notification is made via Explanation of Payment (EOP).
Because of the large volume of claims that CareSource receives and processes, we ask for your cooperation in allowing at least 45 days from submission date before calling about a claim status or submitting a duplicate claim.
How do I check pended claims?
- Claims status is one of many services available to our providers 24 hours a day through our secure Provider Portal. The pended claims report is another resource for claims status and it is sent biweekly.
Can I ever bill my CareSource patients?
A health partner may, upon accepting a patient as a Hoosier Healthwise or Healthy Indiana Plan member, charge the member for non-covered services. In order to charge the member for non-covered services, the health partner must disclose the following in writing:
- That the service to be rendered is not covered by Medicaid.
- Whether there are procedures or treatments covered by the Department that are available to the member in lieu of the non-covered procedure or treatment. If there are covered procedures or treatments available to the member, the member must indicate on the disclosure form his or her willingness to accept the non-covered service.
The member shall sign a statement evidencing his or her knowledge of said disclosures. The statement should also include the cost of the non-covered service and an assurance that there are no other covered services available to the member. In addition, the disclosure statement must contain the payment arrangements. If the member will be subject to collection action upon failure to make the required payment, the terms of said action must be included in the disclosure document. A copy of the disclosure form must be kept in the member’s treatment record. Failure to comply with these procedures will subject the health partner to sanctions, up to and including termination from Hoosier Healthwise and Healthy Indiana Plan.
Additionally, a Medicaid member cannot be denied service because he or she is not able to pay the copayment. However, the health partner may bill the member for the copayment amount.
Coordination of Benefits
How do I determine which plan is the primary payer?
- Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare Managed Care Plans.
How do I know if a member has other coverage?
It is the responsibility of the health partner to verify and obtain all Coordination of Benefits (COB) information at the time of service.
There are two ways to verify:
How do I submit Coordination of Benefits?
Coordination of Benefits (COB) claims can be submitted by mail or electronically.
COB claims should be submitted by mail with the Explanation of Benefits and sent to:
CareSource Attn: Claims Department
P.O. Box 3607
Dayton, OH 45401
For electronic COB claim submissions, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information.
Can I submit Coordination of Benefits claims electronically?
- Yes! CareSource can accept Coordination of Benefits (COB) claims electronically. CareSource accepts both professional claims (CMS-1500) and hospital/facility claims (UB-04) electronically. CareSource’s dental claims are managed through SkyGen, which accepts electronic dental claims through clearinghouses and the SkyGen Portal. We recommend that dental health partners submit claims using ADA forms.
How do I submit Coordination of Benefits claims electronically?
- When submitting Coordination of Benefits (COB) claims electronically, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information. For professional claims (CMS-1500), COB information should be sent at the line level. For hospital/facility claims (UB-04), COB information should be sent at the claim level. In addition to the required COB information, you must send other carrier paid amounts and all claim/line level adjustment group codes, reason codes, remark codes and payment amounts.
Will my claim be rejected if the primary insurance filing timeframes differ from CareSources’s timely filing guidelines?
- If you are not able to submit a claim according to our filing deadline of 90 days, we will accept 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater. Simply submit a copy of the primary carrier’s EOB to CareSource.
What Coordination of Benefits information must be submitted?
For secondary electronic (EDI) professional and institutional claims, the following Coordination of Benefits (COB) information must be submitted:
- Primary Payer Paid Amount: Submit the primary/COB paid amount for each claim reported on the 835 payment or as identified on the explanation of payment (EOP).
- Adjustment Group Code: Submit other payer claim adjustment group codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered service group codes.
- Adjustment Reason Code: Submit other payer claim adjustment reason codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services or HIPAA codes.
- Adjustment Amount: Submit other payer claim adjustment amounts as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services payments.
Where do I include Coordination of Benefits information?
For secondary professional or institutional claims to be paid electronically, all Coordination of Benefits (COB) information must be submitted in the applicable loops and segments. Loops include:
- Loop ID – 2320: Other Subscriber Information
- Loop ID – 2330A: Other Subscriber Name
- Loop ID – 2330B: Other Payer Name
- Loop ID – 2330: Other Provider Information
- Loop ID – 2430: Line Adjudication Information (for professional claims)
If I receive a denial for not supplying Coordination of Benefits, what do I need to do?
Submit a copy of the Explanation of Benefits (EOB) by email, fax or mail:
- Email: IndianaCOB@caresource.com
- Fax: 937-487-1931
P.O. Box 8730
Dayton, OH 45401-8730
You can also submit the claim and EOB electronically. Please refer to your clearinghouse, trading partner or billing administrator to complete this process.
What if I receive a denial for COB and the member’s primary coverage is no longer effective?
What if the Provider Portal is missing information, such as the group number or member’s date of birth?
- Check the carrier’s website or call the carrier directly to obtain the information. We encourage all health partners to verify the patient’s insurance coverage at the time of service.
What are the timely filing guidelines for Coordination of Benefits?
- 90 days from the date of service or 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater.
If I receive a denial showing the member has other coverage, how can I get the other coverage information?
What if I received a letter about a takeback/recoupment indicating that the member has primary insurance?
There are two sources where takeback/recoupment information may come from:
1) Health Management Systems (HMS)
HMS is our third party vendor that identifies if a patient has a primary insurance.
Please send documentation to HMS within 30 days of the recoupment letter. Documentation is typically an EOB showing coverage was not in effect, services were paid or services were denied.
Third Party Recovery Unit
Attn: CareSource COB Project HMS, Inc.
5615 High Point Drive
Irving, TX 75038
Fax: (314) 905-2064
2) Recoupment/Takebacks from CareSource
CareSource will initiate an automatic recoupment in 30 days from the date of notification. If you are disputing the information, send supporting documentation directly to CareSource within 60 days of the recoupment letter date. Documentation is typically an EOB showing coverage was not in effect, services were paid or services were denied.
P.O. Box 8730
Dayton, OH 45401-8730
Should I send a check when I receive the recoupment notification?
- No, you do not need to send a refund check or initiate an adjustment request on these claims unless notified otherwise. The recoupment will be made against future claims payment and will show on the Explanation of Benefit.
What if the primary carrier denies a claim for procedural reasons or if the member is not supplying requested information needed to pay the claim?
CareSource needs a copy of the primary carrier’s Explanation of Benefits denying the claim in order to process the claim within 90 days of our timely filing guidelines:
- The member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire)
- Procedural denial reasons (e.g., timely filing, prior authorization, no referral from primary medical provider)
How does COB work when CareSource is a secondary payer for obstetrician deliveries?
CareSource will deny all prenatal office visits when the explanation for COB information needed has not been provided. Once the primary EOB is received, CareSource will verify if the prenatal visits are a part of the primary payer’s global reimbursement. If they are, CareSource will make no payment until a delivery charge is received. If the prenatal visits are excluded by the primary payer (e.g., maternity benefits not covered by the plan), CareSource will process the claim as if CareSource was the primary payer.
Once the delivery charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary payer’s payment from the Medicaid allowable amount (the benefit allowance for all visits and the delivery charge) and will pay any remaining CareSource allowable payment.
Global Obstetrical Codes are Not Recognized
If the first claim that CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill, within 90 days of the denial or 180 days from the date of service, using the delivery only CPT codes since CareSource does not recognize global obstetrical codes for claims processing.
Once the delivery charge is received, CareSource will determine the Medicaid allowed amount and then subtract the primary insurance paid amount. CareSource will pay any remaining liability up to the Medicaid allowed amount. CareSource will not pay more than the CareSource normal benefit when no other coverage exists.
For OB delivery claims, CareSource will not require the primary payer’s EOB charges to match the charges on the claims submitted to CareSource.
What if the primary payer denies for non-cooperative parent/procedural reasons?
CareSource will require a copy of the primary carrier’s Explanation of Payment (EOP) denial in order to process the claim as primary when claims are denied by the primary carrier for the following reasons:
Member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire)
Procedural denial reasons (e.g., timely filing, prior authorization, referral from primary care provider)
How will CareSource pay claims when the primary insurance’s allowed amount is less than the CareSource allowed amount?
- After the primary insurance pays, CareSource will pay the remainder, up to the lessor of the allowed amounts.
What is CareSource?
CareSource is a nonprofit managed health care organization that serves Medicaid, Marketplace and Medicare consumers; including families with low incomes, children, pregnant women and people who are aged, blind or have disabilities.
We contract with the Indiana Office of Medicaid Policy and Planning (OMPP) to provide services. Our focus is on prevention and partnering with local health care providers to offer the services our members need to remain healthy.
What are the advantages of participating with CareSource?
CareSource’s foundation is our strong partnership with our contracted health partners. Because health partners are so integral to the delivery of services, CareSource offers them a wide array of services and benefits, including:
- Prompt claims payment
- Claims call center
- Paperless referrals and low-hassle medical management
- Web-based transactions and electronic claims submission
- Secure Provider Portal available 24/7 where health partners can perform a variety of functions, including checking eligibility and claim status, submitting prior authorizations and more
- Provider relations staff
- Commitment to service
- Member support services
How can I become a participating health partner?
How can I reach CareSource?
- Call Provider Services at 1-844-607-2831, Monday through Friday, 8 a.m. to 8 p.m., except holidays. Follow the menu options to speak to a representative from the department you need.
How do I make a referral?
CareSource uses a paperless referral system to make it easy for primary medical providers (PMPs) to refer their patients to participating CareSource specialists. To make a referral, PMPs simply:
- Document the referral in the member’s medical chart. Please note the number of visits or length of time for each referral.
- Tell the member how to get the service.
- Notify the specialist of the referral.
Specialists document the referral in the member’s chart as well. Referral forms are not required.
For more information, please visit the Referrals and Prior Authorizations section of the health partner manual.
What benefits does CareSource offer its members?
- CareSource offers its members many extra benefits and support services, such as a 24/7 nurse advice line, free transportation to doctor appointments, case management, coupons for keeping prenatal and postpartum appointments for pregnant members and more. Visit our Prior Authorization page to see benefit limits on select services.