Utilization Management

CareSource® is committed to maintaining the quality and appropriateness of health care services provided to our members. The Utilization Management department performs all utilization management (UM) activities including prior authorization, concurrent review, discharge planning and other activities. CareSource makes its UM criteria available in writing by mail, fax or phone and on this webpage.

Mail: CareSource
P.O. Box 3209
Dayton, OH 45401-3209

Fax: 844-417-6157

On an annual basis, CareSource completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

Prior Authorization

CareSource understands that you may have questions about prior authorization. Access the Prior Authorization webpage for detailed information.

Medical Necessity Criteria

    CareSource applies the Medicare Evidence of Coverage and Summary of Benefits to determine limitations, exclusions and covered benefits for our members. CareSource defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. CareSource complies with all Center of Medicare and Medicaid Services (CMS) payment policies and National Coverage Determinations (NCDs). In the absence of a NCD, CareSource follows the applicable Local Coverage Determinations (LCDs). LCDs are specific written policies made by the Medicare Administrative Contractor (MAC) with jurisdiction for each individual state.

    When services are covered by LCDs from more than one MAC and contractors have different medical review policies, CareSource will apply the LCDs of the contractor in the area where the member resides. It is the policy of CareSource to utilize MCG as our nationally recognized criteria in the absence of an applicable NCD, LCD or other CMS published guidance. In situations where this criteria is absent or not applicable, CareSource may develop criteria based on scientific evidence published in peer reviewed medical literature generally recognized by the medical community, physician specialty society recommendations and the opinions of physicians practicing in clinical areas relevant to the member’s clinical circumstances.

    If the member’s clinical information does not meet the criteria, the case is forwarded to a CareSource Medical Director for further review and determination. Physician reviewers from CareSource are available to discuss individual cases with attending physicians upon request.

    Utilization review determinations are based only on appropriateness of care and service and existence of coverage. CareSource does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

    Our members’ health is always our number one priority. Upon request, CareSource will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CareSource Medical Management Department.

    If you would like to discuss an adverse decision with CareSource’s physician reviewer, please call the Utilization Management Department at 1-833-230-2176 within five business days of the determination. The phone line is an automated system. After the system has completed the introduction, please state the word “extension.” When the system prompts you to state an extension number, please state “12830.” This will prompt the system to forward the call to our dedicated line.

    Access to Staff

    Providers may call our toll free number at 1-833-230-2176 to contact Utilization Management staff with any UM questions.

    • Staff members are available from 8 a.m. to 5 p.m. Eastern Standard Time (EST) Monday through Friday for inbound calls regarding UM issues.
    • Staff members can receive inbound communication regarding UM issues after normal business hours.
    • Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, 7 days a week.
    • Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line and the Provider Portal.
    • Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
    • Staff members are identified by name, title and organization name when initiating or returning calls regarding UM issues.
    • Staff members are available to accept collect calls regarding UM issues.
    • Staff members are accessible to callers who have questions about the UM process.

    In the best interest of our members and to promote their positive health care outcomes, CareSource supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.

    Member Support Services

    Representatives are available to answer member questions regarding UM.

    • Representatives are available by telephone Monday through Friday, except on the following holidays in 2021: Memorial Day (May 31), Independence Day (July 4), Labor Day (September 5), Thanksgiving Day (November 24) and Christmas Day (December 25).
    • Members may call toll-free, 1-833-230-2020 (TTY: 711). We are open 8 a.m. – 8 p.m. Monday through Friday, and from October 1 – March 31 we are open the same hours 7 days a week.
    • CareSource offers language interpreters for members who need assistance to communicate with CareSource to discuss UM issues. These services are available at no cost to the member. As a provider, you are required to identify the need for interpreter services for your CareSource patients and offer assistance to them appropriately.