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.

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 Humana – CareSource. The standard decision time frame for post-service provider appeals is 30 calendar days. A 14 calendar-day extension may be requested on any provider appeal.

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 180 days from the date of the original claim submission denial.

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).

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 180 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 Humana – CareSource® denying coverage, the provider or the member can submit a clinical appeal within 60 calendar days of receipt. Providers must have a member’s written consent 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.

How to Submit Appeals

You can submit appeals through our Provider Portal or using the Kentucky Medicaid MCO Provider Appeal Request 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
  • You can use the Consent For Provider To File An Appeal on Patient/Member’s Behalf form to record this consent.

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 1-855-852-7005 to expedite a clinical appeal.

Notification of Resolution

Humana – 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 three working days of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. Humana – CareSource will send written notification to both the provider and the member on the same business day of the decision.

Denied Expedited Appeals

If Humana – 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 that the member can appeal the decision.  The appeal will be resolved within 30 calendar days from the date the appeal was received and follow the standard Humana – CareSource appeal process.

Extending an Appeal

Members may verbally request that Humana – CareSource extend the time frame to resolve any medical necessity appeal request up to 14 calendar days.

Humana – CareSource may also request that the time frame to resolve a standard or expedited appeal be extended up to 14 calendar days.

For extensions not requested by the member, Humana – CareSource must give the member written notice of the extension, including the reason for the extension, within two calendar days of the decision to extend.

External Independent Reviews

Once a provider exhausts all internal appeal rights, the provider can request an external independent review. Humana – CareSource sends an appeal decision letter with the provider’s external review rights and instructions about how to request the review. You can submit your request for external independent review for dates of service on or after Dec. 1, 2016.

You can submit your request for external independent review through our Provider Portal, by fax or in writing. The request must be submitted within 60 days of receiving the final determination of Humana – CareSource’s internal appeals process.

Fax: 1-855-262-9793

Mail: Humana – CareSource
Attn: Appeals – External Independent Review
P.O. Box 823
Dayton, OH  45401-0823

After Humana – CareSource receives a request from a provider for an external independent review, Humana –CareSource sends the provider an acknowledgement letter within five business days. Humana – CareSource also sends an acknowledgement letter to the member if the request involves an authorization denial.

The external independent review entity issues a final decision within 30 calendar days of receiving the review packet from Humana – CareSource. A provider cannot request an external independent review if the member exercised his/her right for a state hearing.

State Fair Hearings

After members have exhausted their appeal rights, they can request a state fair hearing if Humana – CareSource makes a decision to deny, reduce, suspend or stop care for a member. Members have 120 days from receiving Humana – CareSource’s final decision to file a state fair hearing. 

If Humana – CareSource proposes to reduce, suspend or terminate a service already approved, members may request continuation of benefits until a state fair hearing is held; however, the member may be liable for the cost.

For more information about provider appeals, refer to the provider manual.