Provider Disputes or Appeals

Definitions

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

Clinical Appeals

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 if not submitted by a physician or physician’s representative, require an Authorization of Representative form for dual benefit members and member written consent for Medicaid-Only members.

Provider Disputes

Provider disputes can be submitted via the following:

• Provider portal login
• CareSource Provider Call Center: 1-800-488-0134
• Mail:
  CareSource
  P.O. Box 1947
  Dayton, OH 45401-1947
• FAX: 937-531-2398

Providers may file a written 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 dispute submission, whichever is later.

Submitted disputes should be documented on the Provider Dispute Form (coming soon).

Refer to the Provider Manual for further information related to disputes submission.

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. You may submit this online via the provider portal.

CareSource will resolve and provide written notice to the provider of the disposition of the dispute within 15 business days from the receipt of dispute for claim disputes, and 30 business days for disputes involving medical necessity. 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 claim dispute is needed past 15 business days, then CareSource will provide a status update to the provider every five business days beginning on the 15th business day until the dispute is resolved.

Non-Participating Provider Claim Appeals

Non-participating providers may request reconsideration of a claim denial. You must request an appeal within 60 days of the date of the remittance advice, and a signed Navigate Waiver of Liability (WOL) statement is required. If you do not submit a signed WOL, the appeal will be dismissed.

If you do not agree with a denial on a processed claim, you have 65 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 in the required time frame, CareSource will not reconsider the claim, and the appeal will be dismissed. You will receive notification in writing of the appeal decision. If your 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. You have 365 days from the date of service or discharge to submit a corrected claim. Refer to the Claims page or the Provider Manual for further information related to claims submission.

External Medical Review

Providers who disagree with CareSource’s determination on appeal to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity may request an External Medical Review with Permedion. Services denied, limited, reduced, suspended, or terminated for reasons other than lack of medical necessity and for which no clinical review was completed by CareSource are not subject to External Medical Review. The request for External Review must be submitted to Permedion within 30 calendar days of the date of the internal appeal notification. Providers must complete the “Ohio Medicaid MCE External Review Request” form located at www.hmspermedion.com (select Contract Information and Ohio Medicaid) and submit to Permedion together with the required supporting documentation including:

• Copies of all adverse decision letters from CareSource (initial and appeal)
• All medical records, statements (or letters) from treating health care providers, or other information that provider wants considered in reviewing case

Providers need to upload the request form and all supporting documentation to Permedion’s provider portal located at https://ecenter.hmsy.com/ (new users will send their documentation through secured email at IMR@gainwelltechnologies.com to establish portal access).

An external medical review is a written request for an independent 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: An internal appeal has to be completed before an External Medical Review request is submitted. Additionally, 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.

Clinical Appeals

Peer to Peers are offered when a service authorization is denied for medical necessity. 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, a provider or member can submit a pre-service or post-service clinical appeal. Clinical appeals are reviewed by nurses and physicians not involved in any prior review. They are also reviewed by practitioners with expertise and knowledge appropriate to the item, service, or drug being requested. Refer to the Provider Manual for further information related to clinical appeals submission.

How to Submit Appeals

The most efficient way to submit appeals is through our provider portal. Other options include submittal of a Standard Appeal Form (coming soon) or an Expedited Appeal Form (coming soon).

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 (or signed Appointment of Representative form(coming soon) for dual benefit members), 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 (coming soon) form to record this consent.

Expediting Clinical Appeals

If you feel that the standard pre-service appeal time frame of 15 calendar days could seriously jeopardize the life or health of your patient, or their ability to regain maximum function, you may ask us to expedite a clinical appeal. CareSource does not take any punitive action against providers for supporting their patient’s expedited request. You have 60 calendar days from the date of the receipt of the authorization denial, which is presumed to be 5 days from the date on the notice, to submit an expedited appeal. Documentation for Good Cause for late filing of an appeal will be reviewed. An AOR form or equivalent is required for expedited preservice appeals if submitted by anyone other than the member, or the member’s physician or staff of the physician’s office acting on the physician’s behalf for Medicare or overlap services. A member’s written consent specific to the service requested, only valid for that appeal and must be signed/dated by the member which is appropriate for Medicaid services.

CareSource will review the expedited request as expeditiously as the member’s medical condition requires, and the appeal will be resolved with verbal notification reasonably attempted within 72 hours of receipt of the appeal by the grievance and appeal department, unless the time frame is extended, or the appeal request does not meet expedited criteria.

If the appeal is approved, we will authorize or provide the service in this time frame and include with the notification information about the duration or limitations with approval. CareSource will send an appeal decision letter to the member and representative, if applicable, as well as a copy to the provider within the 72-hour time frame.

If the appeal is denied or partially denied, CareSource will forward the case file to the IRE for Level 2 appeal, or in the event that CareSource does not make a timely decision for Medicare or overlap services. Members may have additional review levels for Medicare services. Members also have additional state hearing rights for denial of overlap and Medicaid services or in the event a decision is not issued in the appropriate time frame.

Please see “Denied Expedited Appeals” for more information about what happens if a request for expedited appeal review is denied, and “Extending an Appeal” for more information about extensions.

Please note, there is a limited amount of time to submit additional information for expedited clinical appeals. CareSource will outreach to the member within one business day about any information needed to evaluate the expedited appeal and will outreach and work with the provider to obtain any needed information for the expedited appeal.

Notification of Resolution

CareSource will decide whether to expedite an appeal within one business day. 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 because the criteria for expedited review are not met, CareSource will transfer the request to a standard appeal time frame beginning the day the expedited request was received. The member will be given prompt oral notice of the decision to not expedite including the member’s expedited grievance rights related to the decision not to expedite the request. A letter will also be sent to the member at the time of the decision, notifying of the decision to not expedite the appeal, the appeal is being transferred the standard appeal time frame of 15 days, and will include any member expedited grievance rights and time frames, and the right to request an expedited appeal with provider support of serious jeopardy to life, health or function.

Extending an Appeal

Members may request that CareSource extend the time frame to resolve any medically necessity appeal request by up to 14 calendar days. CareSource may also request an extension of up to 14 calendar days, if the extension is in the member’s best interest. The plan will make reasonable efforts to provide the member with prompt oral notification of the delay and applicable grievance rights. CareSource will notify the member and their authorized representative in writing of the decision to extend the time frame, the reason for the extension, and applicable grievance rights within two calendar days. CareSource will resolve the appeal as expeditiously as the member’s health condition requires but no later than the date the extension expires. Part B drug appeals may not be extended.

Provider Fair Hearing Plan

Please review Provider Fair Hearing Plan (coming soon) outlining the provider participation plan.

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.