Prior Authorization

CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness and benefit limits.

Services that Require Prior Authorization

Some services that require prior authorization from CareSource include, but are not limited to, the following. Please check benefit coverage and limits before providing services.

  • Intellectual or Developmental Disability (IDD)/Community and Employment Supports (CES) Waiver Services
  • Physical Health Services:
    • All medical inpatient care – including skilled nursing facility, acute, inpatient rehabilitation/therapy, long term and respite care
    • Service provided by all out of-network-providers
    • Elective surgeries (outpatient and inpatient)
    • All clinical trials
    • All unproven, experimental or investigational items and services
    • Non-emergent ambulance services
    • Durable medical equipment (DME) including prosthetic/orthotic devices
    • Home care services and therapies
    • Outpatient therapies
  • Behavioral Health Services:
    • All inpatient stays
    • Residential behavioral health services
    • Partial hospital program service (PHP)
    • Transcranial magnetic stimulation
    • Urine drug testing
    • Outpatient mental health therapy including applied behavioral analysis (ABA)

Prior Authorization Procedures

Providers can request prior authorization by contacting the CareSource Utilization Management Department via:

  • Provider Portal
  • Mail
  • Phone

When submitting an authorization request, please provide the following information:

  • Member/patient name and 11-digit CareSource member ID number
  • Provider name and National Provider Identifier (NPI)
  • Anticipated date of service
  • Diagnosis code and narrative
  • Procedure, treatment or service requested
  • Number of visits requested, if applicable
  • Reason for referring to an out-of-plan provider, if applicable
  • Clinical information to support the medical necessity for the service

The CareSource Provider Portal can accept clinical documentation up to 100 MB.