FAQs

Find answers below to common questions about how to work with HAP CareSource™.

Timely Filing Requirements

  • What are the requirements for timely filing?

    • All HAP CareSource claims that are clean with correct coordination of benefits will now be accepted 180 days from the date of service.
    • Claim appeals will be accepted 30 days from the date of the adverse action, denial of payment, remittance advice, or initial review determination was mailed.

  • How is the filing period counted?

    • Days will be counted from the date of service or the discharge date, whichever is greater.

  • How much time does a health partner have to file if he/she makes an error when submitting a claim?

    • Health partners have 180 days from the date of service to submit a corrected claim. Identify the claim as “Corrected” when resubmitting to HAP CareSource. 

  • Who do health partners contact with questions?

Eligibility

  • How do I check member eligibility?

    • It is important to verify member eligibility before providing services. Patients must be eligible HAP CareSource members at the time of service in order for services to be covered.

      HAP CareSource offers several ways to check member eligibility including by phone or here on our website.

      Phone: 1-833-230-2102
      HAP CareSource Provider Portal available 24/7

  • Can I see a member if my name is not on the member’s card?

    • Yes! Any participating primary care provider (PCP) may see eligible HAP CareSource members. PCPs are responsible for verifying member eligibility before providing any services. Please log on to the HAP CareSource Provider Portal to confirm member eligibility. Please note, eligibility does not guarantee payment of the claim.

Appeals

  • How do I file an appeal?

    • We hope you will be satisfied with HAP CareSource and the service we provide. However, health partners who are unhappy with HAP CareSource’s action concerning a medical necessity decision or a claim payment may appeal it. Please see our Grievances or Appeals page for more information.

  • What if a health partner appeals and the claim is still denied?

    • Appeals that have gone through the formal appeal process are deemed to be final. However, health partners may have administrative law hearing (state fair hearing) rights.

Claims

  • How do I submit a claim?

    • HAP CareSource accepts paper and electronic claims. We encourage you to submit electronic claims through the Provider Portal for quicker processing. Please see the Claims page for more information.

      Health partners have 180 days from the date of service or discharge to submit claims.

  • How can I optimize my claim payment timeframe?

    • Claims submitted electronically are typically received and processed more quickly than paper claims. Health partners may submit claims electronically through the HAP CareSource Provider Portal or through Electronic Data Interchange (EDI) clearinghouses specified by HAP CareSource. For paper claim submissions, we require the most current form versions as designated by the Centers for Medicare & Medicaid Services (CMS), National Uniform Billing Committee (NUBC) and the American Dental Association (ADA). We cannot accept handwritten claims or superbills.

      Tips for submitting paper claims:

        • Use only original claim forms. Do not submit claims that have been photocopied or faxed.
        • Fonts should be 10-14 point (capital letters preferred) with printing in black ink.
        • Do not use liquid correction fluid, stickers, labels or rubber stamps.
        • Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form.
        • Do not include handwritten information on the form.
        • In general, using clean claim forms with legible print will allow for more efficient processing.

  • How soon will I know if my claim was paid?

      • All clean claims will be processed within 15 business days of receipt. Payment notification is made via EOP.

  • How do I check pended claims?

      • Checking claim statuses is one of many services available to our providers 24 hours a day through our secure HAP CareSource Provider Portal. The pended claims report is another resource for claim status and it is sent biweekly.

Billing

  • Can I ever bill my HAP CareSource patients?

    • Health partners may not bill members for any covered services, with the exception of copayments. However, if the member cannot afford their copayment, you must still render services to the member and cannot turn away the member.

Coordination of Benefits

  • How do I determine which plan is the primary payer?

    • Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare managed care plans. 

  • How do I know if a member has other coverage?

    • It is the responsibility of the health partner to verify and obtain all COB information at time of service.

      There are two ways to verify:

      Online: Visit the HAP CareSource Provider Portal to view the COB information on file for the member.
      By phone: Call 1-833-230-2102 and follow the menu prompts.

  • How do I submit Coordination of Benefits?

    • Coordination of Benefits (COB) claims can be submitted by mail or electronically:
      • COB claims should be submitted by mail with the Explanation of Benefits and mailed to HAP CareSource, Attn: Claims Department, P.O. Box 1186, Dayton, OH 45401-1186.
      • COB claims can be submitted on the HAP CareSource Provider Portal which accepts attachments with the claim. 
      • For electronic COB claims submission, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information.

  • Can I submit Coordination of Benefits claims electronically?

    • Yes! HAP CareSource can accept COB claims electronically. HAP CareSource accepts both professional claims (CMS-1500) and hospital/facility claims (UB-04) electronically. HAP CareSource’s dental claims are managed through Delta Dental, which accepts electronic dental claims through clearinghouses and the Delta Dental Portal. We recommend that dental health partners submit claims using ADA forms.

  • How do I submit Coordination of Benefits claims electronically?

    • When submitting COB claims electronically, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information. For professional claims (CMS-1500), COB information should be sent at the line level. For hospital/facility claims (UB-04), COB information should be sent at the claim level. In addition to the required COB information, you must send other carrier paid amounts and all claim/line level adjustment group codes, reason codes, remark codes and payment amounts.

  • What Coordination of Benefits information must be submitted?

    • For secondary electronic data interchange (EDI) professional and institutional claims, the following Coordination of Benefits (COB) information must be submitted:
      • Primary Payer Paid Amount: Submit the primary/COB paid amount for each claim reported on the 835 payment or as identified on the explanation of payment (EOP).
      • Adjustment Group Code: Submit other payer claim adjustment group codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered service group codes.
      • Adjustment Reason Code: Submit other payer claim adjustment reason codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services or HIPAA codes.
      • Adjustment Amount: Submit other payer claim adjustment amounts as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services payments.

  • Where do I include Coordination of Benefits information?

    • For secondary professional or institutional claims to be paid electronically, all COB information must be submitted in the applicable loops and segments. Loops include:
      • Loop ID – 2320: Other Subscriber Information
      • Loop ID – 2330A: Other Subscriber Name
      • Loop ID – 2330B: Other Payer Name
      • Loop ID – 2330: Other Provider Information
      • Loop ID – 2430: Line Adjudication Information (for professional claims)

  • If I receive a denial for not supplying Coordination of Benefits, what do I need to do?

    • Submit a copy of the Explanation of Benefits (EOB) by fax, mail or through the HAP CareSource Provider Portal:
      • By fax: 937-396-3138
      • By mail: HAP CareSource, P.O. Box 1186, Dayton, OH 45401-1186
      • Submit the claims as attachments through the HAP CareSource Provider Portal

        You can also submit the claim and EOB electronically. Please refer to your clearinghouse, trading partner or billing administrator to complete this process.

  • What if I receive a denial for COB and the member’s primary coverage is no longer effective?

  • What if the Provider Portal is missing information, such as the group number or member’s date of birth?

    • Check the carrier’s website or call the carrier directly to obtain the information. We encourage all health partners to verify the patient’s insurance coverage at the time of service.

  • What are the timely filing guidelines for Coordination of Benefits?

    • If a member has other insurance and HAP CareSource is secondary, then the health partner must submit for secondary payment within 90 calendar days of date on the primary carrier’s EOB, but not more than 12 months from the date of service or discharge. Claims that are filed timely with a primary carrier, but did not generate a response from the carrier, despite all reasonable actions taken, must be filed not more than 12 months from the date of service or discharge indicating no response was received. In no event, regardless of cause or circumstance, shall the member be responsible or liable for a claim submitted to HAP CareSource after the expiration of the timely filing deadline.

  • If I receive a denial showing the member has other coverage, how can I get the other coverage information?

  • How does COB work when HAP CareSource is a secondary payer for obstetrician deliveries?

    • HAP CareSource will deny all prenatal office visits when the explanation for COB information needed has not been provided. Once the primary EOB is received, HAP CareSource will verify if the prenatal visits are a part of the primary payer’s global reimbursement. If they are, HAP CareSource will make no payment until a delivery charge is received. If the prenatal visits are excluded by the primary payer (e.g., maternity benefits not covered by the plan), HAP CareSource will process the claim as if HAP CareSource was the primary payer.
    • Once the delivery charge is received, HAP CareSource will combine all prenatal visit charges with the delivery charges. HAP CareSource will subtract the primary payer’s payment from the Medicaid allowable amount (the benefit allowance for all visits and the delivery charge) and will pay any remaining HAP CareSource allowable payment.
    • Global Obstetrical Codes are Not Recognized
    • If the first claim that HAP CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill, within 90 days of the denial or 180 days from the date of service, using the delivery only CPT codes since HAP CareSource does not recognize global obstetrical codes for claims processing.
    • Once the delivery charge is received, HAP CareSource will determine the Medicaid allowed amount and then subtract the primary insurance paid amount. HAP CareSource will pay any remaining liability up to the Medicaid allowed amount. HAP CareSource will not pay more than the HAP CareSource normal benefit when no other coverage exists.
    • For OB delivery claims, HAP CareSource will not require the primary payer’s EOB charges to match the charges on the claims submitted to HAP CareSource.

What if the primary payer denies for non-cooperative parent/procedural reasons?

  • HAP CareSource will require a copy of the primary carrier’s EOP denial in order to process the claim as primary when claims are denied by the primary carrier for the following reasons:
    • Member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire)
    • Procedural denial reasons (e.g., timely filing, prior authorization, referral from primary care provider)

When will HAP CareSource automatically adjust a denied COB claim?

  • HAP CareSource will automatically adjust a claim that originally denied for COB when the following criteria are met:

    Primary insurance has been updated retroactively to show coverage terminated AND The claim was denied for COB within 90 days of receiving the updated information that the primary coverage has been terminated.

    Example:

    • Claim for date of service June 15, 2016 was denied on July 10, 2016 due to the member having primary coverage effective January 1, 2016.
    • HAP CareSource received notification on Sept. 1, 2016 that the other coverage terminated on May 31, 2016.
    • Since the claim was originally processed within the 90-day period of receiving the notification that the primary coverage was terminated, HAP CareSource would automatically adjust the claim.
    • HAP CareSource will not automatically adjust a denied COB claim if the updated coverage was received after 90 days from the denial for COB. The health partner must submit for secondary payment within 90 calendar days of date on the primary carrier’s EOB, but not more than 12 months from the date of service or discharge.

General Questions

  • What is HAP CareSource?

    • HAP CareSource is a joint venture between Health Alliance Plan (HAP) and CareSource. HAP CareSource extends and enhances the mission-based legacies of two midwestern nonprofit organizations to offer comprehensive health coverage, providing access to the best physicians and delivering industry-leading compassion and care.

  • What are the advantages of participating with HAP CareSource?

    • HAP CareSource’s foundation is our strong partnership with our contracted health partners. Because health partners are so integral to the delivery of services, HAP CareSource offers them a wide array of services and benefits, including:
        • Prompt claims payment
        • Claims call center
        • Paperless referrals and low-hassle medical management
        • Web-based transactions and electronic claims submission
        • Secure HAP CareSource Provider Portal available 24/7 where health partners can perform a variety of functions, including checking eligibility and claim status, submitting prior authorizations and more 
        • Provider relations staff
        • Commitment to service
        • Member support services

  • How can I become a participating health partner?

    • Providers can visit our Plan Participation page to learn how to contract with HAP CareSource. Or email ProviderNetwork@HAP.org. We can give you the information you need to start the process of becoming a participating health partner.

  • How can I reach HAP CareSource?

    • Call Provider Services at 1-833-230-2102, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET), except holidays.

  • How do I make a referral?

    • HAP CareSource uses a paperless referral. To make a referral, primary care providers (PCPs) simply:
      • Document the referral in the member’s medical chart. Please note the number of visits or length of time for each referral.
      • Tell the member how to get the service.
      • Notify the specialist of the referral.

        A specialist documents the referral in the member’s chart as well. Referral forms are not required.

        For more information, please visit the Referrals and Prior Authorizations section of the Navigate Provider Manual.
        .

Member Benefits

  • What extra benefits does HAP CareSource offer its members?

      • HAP CareSource offers our members many extra benefits and support services, such as a 24/7 nurse advice line, care management, programs to encourage members to keep prenatal and postpartum appointments, and more.