Provider Appeals

Providers may request the following types of appeals:

  • Claim appeals: Submit a claim appeal to request reconsideration of a claim denial.
  • Clinical appeals: Submit a clinical appeal to request reconsideration of a medical necessity decision.

All appeal requests and associated information are reviewed by clinicians not previously involved with the case.

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.

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 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).

Claim appeals will be resolved within 60 calendar days from the date of receipt.

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.

Clinical Appeals

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 have the right to submit pre-service appeals. Pre-service appeals will be resolved within the standard time frame of 30 calendar days, unless you request an expedited appeal.

The first appeal requested is called a Level 1 appeal. In this appeal, the coverage decision is reviewed to ensure we followed all of the rules properly.

Providers can request a coverage decision or Level 1 appeal on a member’s behalf. If the appeal is denied at Level 1, it will be automatically forwarded to Level 2. Level 2 appeals are conducted by independent organizations not connected to us. For a provider to request any appeal after Level 2, the member must appoint the provider as his or her representative. Learn more about Appointing a Representative here.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). Details of all levels can be found in the provider manual.

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 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

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

Members may verbally request that CareSource extend the time frame to resolve any medically necessity appeal request up to 14 days. CareSource may also request an extension. 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.