Provider Disputes and Appeals
If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claims, you should submit a corrected claim. You do not need to file a dispute or appeal.
Please note: If the claim was denied for a missing consent form or other documentation, the information can be submitted using the Provider Portal, and should not be submitted as a dispute.
What is a Claim Dispute?
A dispute is a formal review of a previous claim reimbursement decision (excluding denials based on medical necessity. Disputes occur when a provider disagrees with payment resulting in an underpayment and any other post-service claim denial.
This is the recommended first step to settling any post-service claim payment concerns.
Process for Claim Payment Disputes
- Claim payment disputes must be submitted in writing.
- The dispute must be submitted within 90 calendar days from the date of the explanation of payment (EOP) or provider remittance advise (PRA).
- At a minimum, the dispute must include:
- Sufficient information to identify the claims in dispute.
- A statement of why you believe a claim adjustment is needed and the desired outcome.
- Pertinent documentation to support the adjustment.
- Incomplete requests will be returned with no action taken. The request must be resubmitted with all necessary information within 90 calendar days of the claim payment or 10 calendar days of the date on the letter notifying you of the incomplete request.
Attn: Provider Appeals Department
P.O. Box 2008
Dayton, OH 45401
CareSource will render a payment dispute decision letter within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication, providers may appeal the claim adjudication if timely rights still exist.
If you do not agree with a denial on a processed claim, you have 365 calendar days from the date of service or discharge, unless otherwise specified in your contract, to submit an appeal.
If the appeal is not submitted in the required time frame, the claim will not be reconsidered and the appeal will be denied. Providers will be notified in writing if the appeal is denied. If the appeal is approved, payment will show on the Explanation of Payment (EOP).
Please note: If you believe a claim processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file an appeal. Providers have 365 days from the date of service or discharge to submit a corrected claim. Also, if a claim was denied for a missing consent for or other documentation, the information can be submitted using the Provider Portal, and should not be submitted as an appeal.
What is a Claim Appeal?
A claim appeal is a written request by a practitioner or organizational provider to review a claim that is believe to have been incorrectly paid or denied due to processing errors.
Process for Submitting Claim Appeals
The claim appeal must be submitted within 365 days from the date of service/discharge, unless otherwise specified in the provider contract, or 90 days from receipt of the primary Explanation of Benefit (EOB).
If the appeal is not submitted in the required timeframe, the claim will not be reconsidered and the appeal will be dismissed. Providers will be notified in writing if the appeal is denied. If the appeal is approved, payment will show on the Explanation of Payment (EOP).
Claim appeals may be submitted via:
If you disagree with a clinical decision we have made regarding medical necessity, we make it easy for you to be heard.
After receiving a letter from CareSource denying coverage, the provider or the member can submit a clinical appeal within 180 calendar days from the date of service, denial or discharge. Providers must have a member’s written consent to file an appeal on behalf of a member and to appeal pre-service issues. The consent must be specific to the service being appealed, is only valid for that appeal and must be signed by the member.
Please be aware that you have Peer to Peer rights that are separate and distinct from your clinical appeal rights. If you received an authorization denial your Peer to Peer rights were provided in your denial letter. Please refer to your denial letter to exercise your available Peer to Peer rights with CareSource.
What is a Clinical Appeal?
A clinical appeal is a written request by a practitioner or organizational provider if you disagree with a clinical decision regarding medical necessity.
Clinical appeals can be submitted in writing by either the provider or member within 180 calendar days from the date of service/discharge. Providers must have member’s written consent to file an appeal on their behalf and/or appeal pre-service issues. The consent must be specific to the service being appealed, is only valid for that appeal and the consent must be signed by the member.
Providers can access the consent form here.
How to Submit Appeals
Include the following required documentation:
- Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested
- Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes
- If the service has already been provided, a copy of the original remittance advice and/or the denied claim
- If filing an appeal on behalf of a member or for pre-service issues, the member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member (Please note: You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form to record this consent.
Expediting Clinical Appeals
If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal.
Call us at 1-800-488-0134 to expedite a clinical appeal.
Notification of Resolution on Expedited Requests
CareSource will decide whether to expedite an appeal within 24 hours. We will make reasonable efforts to provide prompt verbal notification to the member of the decision to expedite or not expedite the appeal; the attempt will be made by phone. If the member is in a facility, the provider or facility will be notified on the same business day of the decision.
Expedited appeals will be resolved and verbal notification will be made within 72 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. CareSource will send written notification to both the provider and the member on the same business day of the decision.
Denied Expedited Appeals
If CareSource decides not to expedite the clinical appeal, we will send written notification within two calendar days of receipt of the appeal to both the member and the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. The appeal will be resolved within 15 calendar days from the date the appeal was received and follow the standard CareSource appeal process.
Extending an Appeal
CareSource must submit documentation that the extension is in the member’s best interest to the Ohio Department of Medicaid (ODM) for prior approval. If ODM approves the extension, CareSource will notify the member in writing of the extension reason and new timeframe.