Provider Disputes or Appeals

Provider Claim Disputes

If you believe a 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.

Process for Claim Payment Disputes:

  • Requests for adjustment for underpayment or overpayment may be submitted through the claim payment dispute process. You do not need to submit an appeal for this type of review.
    • Request for review of a claim denial should be submitted as an appeal.
  • Claim payment disputes must be submitted in writing.
  • The dispute must be submitted within twenty-four (24) months 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 document to support the adjustment
  • Incomplete requests will be returned with no action taken. The request must be resubmitted with all necessary information within ninety (90) calendar days of the claim payment or ten (10) calendar days of the date on the letter notifying you of the incomplete request.
  • 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.

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.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 365 calendar days from the date of service or discharge, unless otherwise specified in your contract, to file a claim 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). For claim denials that are missing documentation, the provider should upload the necessary documentation on the Provider Portal for the claim.

Please note: If you believe a claim 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 an appeal. Providers have 365 days from the date of service or discharge to submit a corrected claim.

Clinical Appeals

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

After receiving a letter from CareSource denying coverage, the provider or the member can submit a clinical appeal within 180 calendar days from the date of service, denial or discharge. Providers must have a member’s written consent via AOR form to file an appeal on behalf of a member and to appeal pre-service issues. The consent must be specific to the service being appealed, is only valid for that appeal and must be signed by the member.

All appeal requests and associated information are reviewed by clinicians not previously involved with the case. Providers do not have appeal rights while the claim is still in process.
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. The standard decision time frame for post-service provider appeals is 30 calendar days.

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.

How to Submit Claim Disputes and Appeals

You can submit claim disputes and appeals through our Provider Portal or using the Navigate Standard Appeal Form. 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.
  • 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.

Now Available: Provider Fair Hearing Plan

The Provider Fair Hearing Plan is now available in a Navigate PDF version. Please review this document outlining the provider participation plan.