Prior Authorization

CareSource North Carolina Co.® 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 North Carolina Co. should be authorized before the service is delivered. CareSource North Carolina Co. is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.

Prior Authorization Procedures

The Provider Portal is the preferred and fastest method to request a prior authorization for health care services. You can receive immediate approval and review the status of an authorization.

If you need assistance with submitting your prior authorization or have questions regarding submissions via the portal, please email us and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. For additional information or questions about CareSource North Carolina Co. benefits, please visit the Navigate Provider Manual or contact Provider Services. 

Alternate methods include phone or mail.

Phone: 1-833-230-2101
Fax: 1-844-676-0372

Mail: CareSource North Carolina Co.
P.O. Box 1307
Dayton, OH 45401-1307

Written prior authorization requests should be submitted on the Navigate Medical Prior Authorization Request Form.

Nonparticipating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

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 1-833-230-2101 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.

Please call 1-833-230-2101 for any questions related to post-stabilization services.