Provider Disputes and Appeals

Definitions

CareSource provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Claim Dispute

A dispute is the first formal review of the processing of a claim by CareSource (excluding denials based on medical necessity) and is typically submitted prior to submitting a claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial.

Claim Appeals

A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors.

Peer-to-Peer

Peer-to-peer rights 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 from CareSource. Please refer to your denial letter to exercise your available peer-to-peer rights. CareSource provides peer-to-peer reviews as an additional level of review for your pre- or post-service medical necessity requests, and they must be completed prior to you submitting a clinical appeal.

Clinical Appeals

A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the CareSource Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are clinical appeals and require the member’s written consent. For more information about requirements for pre- and post-service appeals, view the Clinical Appeals section below.

Claim Disputes

If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file a dispute. Refer to the Claims page or the Provider Manual for further information related to claims submission. If you have made reasonable attempts to correct a claim and you remain dissatisfied with the disposition, you may submit a claim dispute stating why you disagree.

Claim disputes:

  • Must be submitted within 60 days of the written determination of the claim
  • Must be submitted through the Provider Portal (the most efficient method) or the Claim Dispute Form 
  • Must be completed before requesting a claim appeal

Appeals

All appeal requests and associated information are reviewed by clinicians not previously involved with the case.

Include the following required documentation:

  • Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested.
  • Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes.
  • If the service has already been provided, a copy of the original remittance advice and/or the denied claim.
  • If filing an appeal on behalf of a member or for pre-service issues, the member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. Please note: You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form to record this consent.

Claim Appeals

Providers must exhaust the claim dispute process as outlined above before filing a claim appeal.

Claim appeals must be submitted:

Claims appeals filed without first submitting a dispute will not be processed.

Arbitration Process: If you are dissatisfied with the decision of the claim appeal, you may submit the matter to binding arbitration. The binding arbitration process must be conducted in accordance with the rules and regulations of the American Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as adopted in the State of Indiana at IC-34-57-2-2.

Clinical Appeals

If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from CareSource denying coverage, a provider or member can submit a pre-service or post-service clinical appeal.

  • denial of an authorization for a service prior to being completed. You have 60 calendar days from the date of action notice to submit a pre-service appeal. For pre-service appeals submitted with written member consent, the standard appeal decision time frame is 30 calendar days from the date of receipt by CareSource. A 14 calendar-day extension may be requested by CareSource.
  • denial of an authorization for a service that has already been completed. You have 60 days from date of service, discharge or authorization denial to submit a post-service appeal. Member consent is not required for post service requests. The standard decision time frame for post-service provider appeals is 30 calendar days. A 14 calendar-day extension may be requested by CareSource on any provider appeal.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal.

Expediting Clinical Appeals

If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal.

Call us at 1-855-202-1058 to request an expedited a clinical appeal.

Notification of Resolution

CareSource will decide whether to expedite an appeal within 48 hours/two (2) days. We will make reasonable efforts to provide prompt verbal notification to the member of the decision to expedite or not expedite the appeal; the attempt will be made by phone.

Expedited appeals will be resolved, and verbal notification will be made within 48 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. CareSource will send written notification to both the provider and the member on the same business day of the decision.

Denied Expedited Appeals

If CareSource decides not to expedite the clinical appeal, we will send written notification within two calendar days of receipt of the appeal to both the member and the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. The appeal will be resolved within 30 calendar days from the date the appeal was received and follow the standard CareSource appeal process.

Extending an Appeal

Members may verbally request that CareSource extend the time frame to resolve any medical necessity appeal request up to 14 days. CareSource may also request an extension. Member may verbally request that CareSource extend the timeframe to resolve any medical necessity appeal request up to 14 calendar days. CareSource may also request an extension. CareSource will provide a written notice for the extension.

External Review

The member or their authorized representative has the right to request an independent external review within 33 calendar days from the date of the appeal determination.

The Independent Review Organization (IRO) will make a decision to uphold or reverse the decision within 72 hours for an expedited appeal, or 15 business days for a standard appeal. The determination made by the independent review organization is binding.

Providers may send external review requests to:

CareSource
P.O. Box 8738
Dayton, OH 45401-8738
Attn: Independent Review – Appeals Dept.
Fax: 844-417-6262

Updates & Announcements

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to our Updates & Announcements page for notifications of changes that may impact your appeal.

Contact Us

For any questions regarding CareSource’s processes, please contact Provider Services at 1-844-607-2831, Monday through Friday, 7 a.m. to 7 p.m. Eastern Standard Time (EST).