CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.
Use the 2020 Quick Reference Guide to check the services and codes that require prior authorization for CareSource’s plans.
Prior Authorization Procedures
Request prior authorization for health care services via the Provider Portal or by phone, fax or mail.
P.O. Box 1307
Dayton, OH 45401-1307
Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:
All in-patient services require prior authorization. Please call 1-866-286-9949 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.
Post Stabilization Services
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.
To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please call 1-866-286-9949 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Medical Management department.
Please call 1-866-286-9949 for any questions related to post-stabilization services.
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.
Dental Prior Authorization
Marketplace dental providers can submit a dental authorization request via the DentaQuest Provider Web Portal.