Provider Appeals

Providers may request the following types of appeals:

  • Claim appeals: Submit a claim appeal to request reconsideration of a claim denial.
  • Clinical appeals: Submit a clinical appeal to request reconsideration of a medical necessity decision.

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

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.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 60 calendar days from the date of service or discharge, unless otherwise specified in your contract, to submit an appeal.

If the appeal is not submitted in the required time frame, the claim will not be reconsidered and the appeal will be denied. Providers will be notified in writing if the appeal is denied. If the appeal is approved, payment will show on the Explanation of Payment (EOP).

Claim appeals will be resolved within 60 calendar days from the date of receipt.

Please be aware: Network providers do not have appeal rights and must use the payment dispute process to address any claims payment issues.

Clinical Appeals

Medicare providers who are in CareSource’s network and are participating for CareSource members must use the dispute process for any claim denials. Appeal rights do not exist for participating Medicare providers.

If you believe your claim was denied incorrectly or underpaid, you can submit a claim dispute.

Claim payment disputes must be submitted in writing which can done by using the CareSource provider portal. The dispute must be submitted within ninety (90) calendar days of the date of denial or date of payment.

How to Submit Appeals

You can submit appeals over the phone, through our Provider Portal or by using the Provider Appeal Form (coming soon). The Provider Portal is the most efficient method of submitting appeals.

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

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, the ordering physician may ask us to expedite a clinical appeal.

Call us at 1-844-679-7865 to expedite a clinical appeal.

Notification of Resolution

CareSource will decide whether to expedite an appeal within 24 hours. 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. If the member is in a facility, the provider or facility will be notified on the same business day of the decision.

Expedited appeals will be resolved and verbal notification will be made within 72 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 medically necessity appeal request up to 14 days. CareSource may also request an extension.