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:

Provider Claim Dispute

Provider claim disputes are defined as outlined in OAC 5160-26-05.1 – PA A.6.f.i.2 as any provider inquiries, complaints or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim denial.

• They do not include inquiries that come through ODM’s Provider Web portal (HealthTrack).
• Provider claim disputes do not include provider disagreements with the decision to deny, limit, reduce, suspend or terminate a covered service for lack of medical necessity that are subject to external medical review.

Provider claim disputes must be received at CareSource no later than 12 months (365 calendar days) from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later (i.e. claim recovery/recoupments).

Submitted complaints should include:

• The member’s name, CareSource member ID number and date of birth.
• The provider’s name, CareSource provider billing number and rendering National Provider Identifier (NPI).
• The claim number, date, type and place of service.
• Code/Service in dispute.
• Reason(s) for the dispute request and reconsideration.
• Copy of the Explanation of Payment (EOP) and any other documentation to support the dispute.

External Medical Review

An external medical review is a written request for an external medical review in which a provider may be unsatisfied with our decision to deny, limit, reduce, suspend or terminate a covered service for lack of medical necessity. NOTE: Services that are denied for reasons other than lack of medical necessity (i.e. the service is not covered by Medicaid) are not subject to external medical review.

The external medical review process does not interfere with the provider’s right to request a peer-to-peer review, or a member’s right to request an appeal or state hearing, or the timeliness of appeal and/or state hearing resolutions.

Provider 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.

Process for Provider Claim Disputes

• Provider claim disputes can be submitted via the Provider Call Center, provider advocates or the CareSource Provider Portal.
• Providers may file a written claim dispute no later than 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, which is later.
• Submitted complaints should include:
  • The member’s name, CareSource member ID number and date of birth.
  • The provider’s name, CareSource provider billing number and rendering National Provider Identifier (NPI).
  • The claim number, date, type and place of service.
  • Code/Service in dispute.
  • Reason(s) for the dispute request and reconsideration.
  • Copy of the EOP and any other documentation to support the dispute.

Providers may file a written or verbal claim dispute no later than 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, which is later.

Phone: 1-833-230-2101
Online: Provider Portal
Fax: 937-531-2398

CareSource will resolve and provide written notice to the provider of the disposition of the claim dispute within 15 business days from the receipt of dispute. Written notice will not be provided if the dispute was resolved with an initial phone call or person-to-person contact.

Extending a Dispute

If additional time to resolve a dispute is needed past 15 business days then CareSource will provide a status update to the provider every five business days beginning on the 15^th business day until the dispute is resolved.

Provider Claim Appeals (Non-Clinical)

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.

NOTE: Providers must exhaust our claim dispute process prior to filing a claim appeal.

NOTE: If your denial is tied to an Authorization requirement, please skip to the Clinical Appeals section.

If you do not submit an appeal within 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, notification of decision will be provided in the form of an 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 by using the appropriate process. Please click here for the process.

Claim appeals may be submitted via:

• Online: Provider Portal
• Fax: 937-531-2398

Peer-to-Peer Process (Prior Authorization Denials Only)

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 (Prior Authorization Denials Only)

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 to our Utilization Review Team for consideration.

How to Submit Appeals

You can submit appeals through our Provider Portal or using the Navigate Provider 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 Navigate 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 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.

Now Available: Provider Fair Hearing Plan

The Provider Fair Hearing Plan is now available in a Navigate PDF version. Please review this document outlining the provider participation plan.

External Medical Review

In the event a provider is unsatisfied with CareSource’s decision to deny, limit, reduce, suspend or terminate a covered service for lack of medical necessity you can request an external medical review. An external medical review must be submitted within 30 calendar days after the provider’s receipt of CareSource’s resolution at no cost.

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, 7 a.m. to 8 p.m. Eastern Standard Time (EST).