Provider Disputes and Appeals

Definitions

CareSource provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

  • Claim Dispute – A dispute is the first formal review of the processing of a claim by CareSource (excluding denials based on medical necessity) and is typically submitted prior to submitting a claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial.
  • Claim Appeal – A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors.
  • Peer-to-Peer – Peer-to-peer rights 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 from CareSource. Please refer to your denial letter to exercise your available peer-to-peer rights. CareSource provides peer-to-peer reviews as an additional level of review for your pre- or post-service medical necessity requests, and they must be completed prior to you submitting a clinical appeal.
  • Clinical Appeal – A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the CareSource Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are clinical appeals and require the member’s written consent. For more information about requirements for pre- and post-service appeals, view the Clinical Appeals section below.

Claim Disputes

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. Refer to the Claims page or the Provider Manual for further information related to claims submission.

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.

Process for Claim Disputes

  • Claim 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.

Online: Provider Portal

Fax: 937-531-2398

Mail: CareSource
Attn: Provider Appeals Department
P.O. Box 2008
Dayton, OH 45401

CareSource will render a claim dispute decision letter within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication, you may appeal the claim adjudication decision if timely filing rights still exist.

Claim Appeals

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 you do not submit an appeal submitted in the required time frame, CareSource will not reconsider the decision, and the appeal will be denied. You will receive notification in writing if the appeal is denied. If the appeal is approved, your payment will appear 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.

Claim appeals may be submitted via:

Peer-to-Peer Process

CareSource provides the opportunity for providers to discuss the Utilization Management (UM) medical necessity determination of a denial or decrease in level of care with CareSource’s Medical Director/Behavioral Health Medical Director or designee within five business days of the notification of the determination. The peer-to-peer process is independent of the appeal process and does not impact the timeframe a member and/or provider has to appeal.

To initiate the peer-to-peer process, please call CareSource’s Utilization Management team at 1-833-230-2168.

Clinical Appeals

If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from CareSource denying coverage, a provider or member can submit a pre-service or post-service clinical appeal.

  • Pre-Service Appeal: denial of an authorization for a service prior to being completed. You have 60 days from the date of the authorization denial to submit a pre-service appeal. The pre-service appeal must be accompanied with a member’s written consent, must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member.
  • Post-Service Appeal: denial of an authorization for a service that has already been completed. You have 180 days from date of service, discharge or authorization denial to submit a post-service appeal. Member consent is not required for post service requests.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal.

How to Submit Appeals

You can submit appeals through our Provider Portal or using the NavigateProvider Appeal Form. The Provider Portal is the most efficient method of submitting 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 NavigateConsent 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 request an expedited 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.

Updates & Announcements

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to our Updates & Announcements page for notifications of changes that may impact your appeal.

Contact Us

For any questions regarding CareSource’s processes, please contact Provider Services at 1-800-488-0134, Monday through Friday, 8 a.m. to 6 p.m. Eastern Standard Time (EST).