Provider Disputes or Appeals
Definitions
CareSource North Carolina Co.® provides the following opportunities for you to request review of claim or authorization details. Actions available after a denial include:
Claim Appeals
A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors.
Clinical Appeals
You can submit appeals through our Provider Portal or using the Standard Appeal Form. The Provider Portal is the most efficient method of submitting appeals.
A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity on behalf of the member. Clinical denials are issued from the CareSource North Carolina Co.® Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are clinical appeals and require the member’s signed and dated Appointment of Representative (AOR). For more information about requirements for pre-and post-service appeals, view the Clinical Appeals section.
Updates & Announcements
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 grievance.
Contact Us
For any questions regarding CareSource North Carolina Co.’s processes, please contact Provider Services at 1-833-230-2101, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET).