Provider Disputes and 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.
For pre-service appeals submitted with written member consent, the standard appeal decision time frame is 15 calendar days from the date of receipt by CareSource. The standard decision time frame for post-service provider appeals is 30 calendar days. A 14 calendar-day extension may be requested on any provider appeal.
If you do not agree with a denial on a processed claim, you have 60 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 dismissed. Providers will be notified in writing of the appeal decision. 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.
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 60 calendar days from the date of service, denial or discharge. Providers must have a member’s written consent (or a signed AOR for opt-in members) 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.
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 (or signed AOR for opt-in 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 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.
Claim Payment Dispute Process
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.
Process for Claim Payment Disputes:
- Requests for adjustment for underpayment or overpayment may be submitted through the claim payment dispute process. You do not need to submit an appeal for this type of review.
- Request for review of a claim denial should be submitted as an appeal.
- Claim payment disputes must be submitted in writing.
- The dispute must be submitted within 60 calendar days of the date of payment.
- 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.
- Pertinent document to support the adjustment.
- Incomplete requests will be returned with no action taken. The request must be resubmitted with all necessary information within 60 calendar days of the claim payment or 10 calendar days of the date on the letter notifying you of the incomplete request.
- Payments can be submitted to CareSource through the following methods:
Online: Provider Portal
Attn: Provider Appeals Department
P.O. Box 1947
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.