Provider Disputes or Appeals

Definitions

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

Claim Appeals

A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors. For out-of-network providers, please refer to the Non-Participating Provider Appeals and Disputes.

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 by participating providers prior to claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial. CareSource pays non-contracted providers, as Medicare would have paid for the same service. If your disagreement is limited to the amounts a non-contracted provider could collect if the beneficiary were enrolled in original Medicare pursuant to § 422.214(a)(l), you should use the plan’s internal payment dispute process and submit your claim payment dispute to:

CareSource
Attn: Provider Disputes
P.O. Box 1947
Dayton, OH 45401-1947

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 opt-in members and member written consent for opt-out members.

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 should not file a dispute or appeal. A Correct Claim should be submitted. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Please note: All Non-participating providers should submit their claim issues as Claim Appeals and not as a Payment Dispute.

Claim Dispute Process

Requests for adjustment for underpayment or overpayment may be submitted through the claim payment dispute process. You should not submit an appeal for this type of review.

A request for review of a claim denial should be submitted as an appeal if the denial was for lack of authorization or insufficient authorization.

Claim 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.

Claim disputes can be submitted to CareSource through the following methods:

  • Online: Provider Portal
  • Fax: 937-531-2398
  • Mail:
    CareSource
    Attn: Provider Appeals
    P.O. Box 1947
    Dayton, OH 45401-1947

Mail submissions are only excepted if the attachment is greater than 100 MB and not able to be submitted through the portal.

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 if timely filing rights still apply.

Claim Appeals

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 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.

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, 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.

  • Pre-Service Appeal: Denial of an authorization for a service prior to being completed. An appeal may be submitted by the member, provider, or a representative of the member with Authorization of Representative form or equivalent (appropriate for Medicare or overlap services), or member’s written consent specific to the service requested, only valid for that appeal and must be signed/dated by the member which (appropriate for Medicaid services). Standard appeals may be submitted 60 days from the date of the receipt of the authorization denial, which is presumed to be five days from the date on the notice, to submit a standard pre-service appeal. This is considered a member appeal and will be resolved within 15 days plus any extension, if applicable, for a standard appeal with a letter sent to the member, representative if applicable, and copy to the provider. See ‘Extending an Appeal” for more information on extensions. Part B drug standard appeals will be resolved within seven days and may not be extended. CareSource will review documentation for Good Cause for late filing of an appeal. Please see ‘Expediting Clinical Appeals’ for more information on expedited clinical appeals. Pre-Service appeals for Medicare or overlap services that are not approved by CareSource are forwarded to the Independent External Reviewer (IRE) by CareSource for Level 2 appeal, or in the event that CareSource does not make a timely decision. 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.
  • Post-Service Appeal: Denial related to a service that has already occurred and may include a review for medical necessity. Providers may refer to the process for Claim Disputes and Claim appeals for more information. Non-participating providers may submit a claim appeal within 60 calendar days from the remittance notification date, which may include clinical review for medical necessity. Please refer to “Non-Participating Provider Appeals and Disputes” for more information. Non-contract provider appeals that are not approved by CareSource are forwarded to the IRE by CareSource for Level 2 appeal, or in the event that CareSource does not make a timely decision for Medicare or overlap services. Provider post-service appeals are resolved within 30 days. Member post-service appeals are resolved within 15 days.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization this is considered a claim appeal and should not be submitted as a retro-authorization.

How to Submit Appeals

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

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 Navigate Appointment of Representative form 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 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 the standard pre-service appeal time frame of 15 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 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 24 hours 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 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 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 days. CareSource may also request an extension of up to 14 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.

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.

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 Time (ET).