Claim Payment Disputes

If you believe the claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You do not need to file a dispute or appeal. Corrected claims should not be submitted as part of an appeal or dispute. Refer to the Claims page by clicking the Claims link on the menu to the left or the Provider Manual for further information related to claims submission.

Process for Claim Payment Disputes:

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

Claim payment disputes must be submitted in writing.

If your denial involves a denied authorization request involving a medical necessity review, you must submit an appeal. The dispute must be submitted within ninety (90) calendar days of the date of denial or date of payment.

At a minimum, the dispute must include:

  • Sufficient information to identify the claim(s) in dispute
  • A statement of why you believe a claim adjustment is needed
  • Pertinent documentation to support the adjustment

Incomplete requests will be returned with no action taken. Payments disputes can be submitted to CareSource through the following methods:

CareSource will render a decision within thirty (30) calendar days of receipt. If the decision is to uphold the original claim adjudication, providers may appeal. Appeals must be submitted within 365 days of the date of the denial.