Utilization Management

    We are committed to ensuring the quality and appropriateness of health care services provided to our members. The Utilization Medical Management department performs all UM 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, phone or email and on this webpage. We make our UM criteria available on this webpage and in writing through the following forms of communication:

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

    Fax: 1-888-752-0012

    On an annual basis, we complete an assessment of satisfaction with the UM process and identify any areas for improvement opportunities.

    Access to Staff 

    Providers may call our toll-free number at 1-800-488-0134 for assistance with any UM questions.

    • Staff members are available from 8 a.m. to 5 p.m. Eastern Time (ET) 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, seven 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.

    Medical Necessity Criteria 

    We utilize nationally recognized criteria to determine medical necessity of inpatient hospital and rehabilitation admissions These criteria are designed to assist health care providers in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. We default to all applicable state and federal guidelines regarding criteria for authorization of covered services. We also have policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a Medical Director for further review and determination. Physician reviewers are available to discuss individual cases with attending physicians upon request.

    Utilization review determinations are based only on medical necessity and existence of coverage. We do not reward health care providers 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, we will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing our Utilization Management department. If you would like to discuss an adverse decision with physician reviewer, please call the Utilization Management department at 1-800-488-0134 within five business days of the determination.

    Prior Authorization

    We understand that you may have questions about prior authorization. Please visit our Prior Authorization page for more information.