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Frequently Asked Questions

  • Eligibility

    • Why can't I check future eligibility of a member?
      • CareSource Advantage® (HMO SNP) members are dual eligible and must maintain eligibility for Medicare and Medicaid. All Medicaid recipients receive eligibility from the state on a month to month basis. Because of this, CareSource cannot be provided member eligibility for the upcoming months.

    • Can a member be retro termed?
      • Yes, a member's eligibility can be retro termed at any point during the month by the Center of Medicare and Medicaid Service (CMS).

    • How do I check member eligibility?
      • It is important to verify member eligibility before providing services. Patients must be eligible CareSource members at the time of service in order for services to be covered.

        CareSource offers several ways to check member eligibility including by phone or here on our website.

        Phone: 1-800-390-7102
        Provider Portal: Available 24/7

        For more information, please see How To Check Member Eligibility.

    • Can I see a member if my name is not on the member's card?
      • Yes! Any participating PCP may see eligible CareSource members. PCP's are responsible for verifying member eligibility before providing any services. Please log onto the Provider Portal to confirm member eligibility. Please note eligibility does not guarantee payment of the claim.

  • Appeals

  • Claims

    • How do I submit a claim?
      • CareSource accepts claims in a variety of formats, including paper and electronic claims for up to 365 days from date of service or date of discharge.

        Electronic claims:

        CareSource accepts electronic claims in the following file formats:

        • 837 ANSI ASC x 12N (004010A) for professional and claims, including translation and communications software, enables computers to perform EDI transactions accurately and efficiently.

        We recommend you include your CareSource Provider billing number on all claims. If you are unsure of your provider billing number, please call Provider Services at 1-800-390-7102.

        To submit claims electronically, providers must work with an electronic claims clearinghouse. CareSource currently accepts electronic claims through Emdeon, Netwerkes and Practice Insights.

        For more information, please see Submit a Claim.

        Paper claims:

        CareSource accepts paper claims on the following forms:

        • CMS 1500, formerly HCFA 1500 form - AMA universal claim form also known as the National Standard Format (NSF)
        • CMS 1450/UB04, formerly UB92 form (for hospitals)
        • ADA J400 - ADA J400

        Please send all paper claims to:

        P.O. Box 1307
        Dayton, OH 45401-1307
    • How can I optimize my claim payment timeframe?
      • EDI claims are typically received and processed more quickly than paper claims. We require paper claim submission using the most current form version as designated by CMS, NUCC and the ADA. We cannot accept handwritten claims or SuperBills.

        Tips for Submitting Paper Claims:

        • Use only original claim forms. Do not submit claims that have been photocopied or faxed
        • Fonts should be 10-14 point (capital letters preferred) with printing in black ink
        • Do not use liquid correction fluid, stickers, labels or rubber stamps
        • Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form
        • Do not include handwritten information on the form
        • We recommend including your 12 digit CareSource provider ID, which allows for fastest paper claim processing
        • In general, using clean claim forms with legible print will allow for more efficient processing
    • How soon will I know if my claim was paid?
      • The majority of clean claims are processed within 30 days; we strive to process all claims received within 90 days. Payment notification is made via EOP (Explanation of Payment).

        Because of the large volume of claims that CareSource receives and processes, we ask for your cooperation in allowing at least 45 days from submission date before calling about a claim status or submitting a duplicate claim.

    • How do I check pended claims?
      • Claims status is one of many services available to our providers 24 hours a day through our secure Provider Portal. The pended claims report is another resource for claims status and it is sent bi-weekly.

  • Billing

    • Can I ever bill my CareSource patients?
      • State and federal regulations prohibit health care providers from billing CareSource members for services provided to them except under specific circumstances. Please remember that regulations state that health care providers must hold members harmless in the event that CareSource does not pay for a covered service performed by a provider unless CareSource denies prior authorization of the service. In this instance, the provider must notify the member in writing that the member is financially responsible for the specific service. This must be completed prior to providing the service and the member must sign and date the notification. CareSource members are not responsible for any co-payments on Medicaid services provided by CareSource. 

  • Prior Authorization

    • How do I obtain Prior Authorization?
      • Providers can obtain Prior Authorization for health care services by contacting the CareSource Medical Management Department by phone, fax, mail, online Provider Portal or e-mail. Requests can be submitted on the Prior Authorization Request Form.

        Submit a PA Request:

        • Online Prior Authorization
        • By phone: 1-800-390-7102
        • By fax: 1-888-577-5507
        • By mail:
          Attn: Medical Management Department
          P.O. Box 1307
          Dayton, OH 45401-1307
    • Is authorization needed for referrals to specialists?
      • A referral is required for CareSource members to be evaluated or treated by most participating specialists. A Prior Authorization is needed to refer a member to a non-participating provider. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the PCP. Please see the CareSource Provider Manual for more details.

    • Is authorization needed for outpatient, non-emergent diagnostic procedures?
      • Yes. Prior authorization is required for outpatient, non-emergent diagnostic procedures. Please refer to our section on Prior Authorization for how to submit, and what requires Prior Authorization.

    • Is authorization required for an observation?
      • Authorization for an observation stay in a participating facility is not required. An observation in a non-participating facility does require an authorization and must be reported to the Medical Management Department.

    • Does CareSource require authorization if the member has primary insurance?
      • Prior Authorization is not required when CareSource is the secondary payer for medical services.

        Prior Authorization is required for any dental request listed on the Prior Authorization list when CareSource is the secondary payer.

    • How do I request a Retrospective Review?
      • Providers have 180 days from the date of service, date of discharge or 180 days from another carrier’s denial on an Explanation of Payment (EOP) whichever is later to request a retrospective review for medical necessity. The retrospective review requests must include a copy of the other carrier’s EOP. All requests for services will be reviewed for timeliness and medical necessity.

        Providers can request a retrospective review by contacting the Medical Management Department at 1-800-390-7102, or by faxing the request to 1-888-527-0016. Clinical information supporting the request for services must accompany the request.

  • Member Benefits

  • Coordination of Benefits (COB)

    • How do I determine which plan is the primary payer?
      • Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare Managed Care Plans. The only exception is BCMH (Bureau for Children with Medical Handicaps), where Medicaid would be considered primary.

    • How do I know if a member has other coverage?
      • It is the responsibility of the provider to verify and obtain all Coordination of Benefits information at time of service. There are two ways to verify, check online or call:

        • Online: Visit the Provider Portal to view the Coordination of Benefits information that CareSource has on file for the member.
        • By phone. Call 1-800-390-7102 and follow the menu prompts.
    • How do I submit Coordination of Benefits?
      • Coordination of Benefits claims should be submitted by mail with the Explanation of Benefits and mailed to:

        P.O. Box 1307
        Dayton, OH 45401-1307

        Take me to a form: 1500 Claim form, UB-04, ADA J400

    • If I receive a denial for Coordination of Benefits, what do I need to do?
      • Submit a copy of the Explanation of Benefits by email, fax or mail:

        • Contact form:Click Here
        • By fax: Fax (937) 396-3140
        • By mail:

          P.O. Box 1307
          Dayton, OH 45401-1307
    • What If I receive a denial for COB and the member’s primary coverage is no longer effective?
      • Call Provider Services: 1-800-390-7102. Once CareSource confirms that the member no longer has primary coverage, the member is updated in our system.

    • What if the Provider Portal is missing information, such as the Group Number or Member’s date of birth?
      • Check the carrier’s website or call the carrier directly to obtain the information. We encourage all providers to verify the patient’s insurance coverage at the time of service.

    • What are the timely filing guidelines for Coordination of Benefits?
      • 365 days from the Date of Service, OR 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater.

    • Will my claim be rejected if the primary insurance filing timeframes differ from CareSource’s timely filing guidelines?
      • If you are not able to submit a claim according to our filing deadline of 365 days, we will accept 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater. Simply submit a copy of the primary carrier’s EOB to CareSource.

    • If you receive a denial showing the member has other coverage, how can I get the other coverage information?
      • Online. You can obtain the other coverage information that CareSource has on file by reviewing the member's eligibility information on our Provider Portal.

        By phone. Call 1-800-390-7102 and follow the menu prompts.

    • What if I received a letter about a takeback/recoupment indicating that the member has primary insurance?
      • There are two sources where takeback/recoupment information may come from:

        1) Health Management Systems (HMS)
        HMS is our third party vendor that identifies a patient has a primary insurance.

        Please send documentation to HMS within 30 days of the recoupment letter. Documentation is typically an EOB showing coverage was not in effect, services were paid, or services denied.

        Third Party Recovery Unit
        Attn: CareSource COB Project HMS, Inc.
        5615 High Point Drive
        Suite 100
        Irving, TX 75038
        (877) 259-3308
        Fax: (314) 905-2064

        2) Recoupment/Takebacks from CareSource
        CareSource will initiate an automatic recoupment in 30 days from the date of notification. If you are disputing the information, send supporting documentation directly to CareSource within 60 days of the recoupment letter date. Documentation is typically an EOB showing coverage was not in effect, services were paid, or services denied.

        Send this to:

        CareSource COB
        P.O. Box 1307
        Dayton, OH 45401-1307
    • Should I send a check when I receive the recoupment notification?
      • No, you do not need to send a refund check or initiate an adjustment request on these claims. The recoupment will be made against future claims payment and will show on the Explanation of Benefit.

    • What if the Primary Carrier denies a claim for procedural reasons or if the member is not supplying requested information needed to pay the claim?
      • CareSource needs a copy of the primary carrier's Explanation of Benefits denying the claim in order to process it within 365 days of our timely filing guidelines:

        • The member did not supply the requested information (For example, accident/injury questionnaire, full-time student questionnaire).
        • Procedural denial reasons (For example, timely filing, prior authorization, no referral from Primary Care Provider).
    • The member’s primary insurance requires prior authorization for inpatient rehabilitation and so does CareSource. Do I need to obtain prior authorizations from both plans?
      • Providers must comply with the plan rules of the primary insurance carrier. If the primary carrier makes payment on the claim, a second authorization from CareSource is not required. The claim should then be submitted to CareSource as secondary. We will reimburse for this service if the primary payment is less than our allowable rate. If the primary denies the claim for procedural reasons, CareSource becomes the primary plan and therefore, prior authorization would be required.

    • Are there cases where I would receive an adjustment when a COB claim originally denied?
      • When CareSource Will Automatically Adjust a Denied COB Claim:

        CareSource will automatically adjust the claims that originally denied for COB when the following criteria are met:

        • Primary insurance has been updated retroactively to show coverage terminated AND
        • The claim was denied for COB within 90 days of receiving the updated information that the primary coverage has been terminated


        • Claim for date of service 6/15/10 was denied on 7/10/10 due to the member having primary coverage effective 1/1/10.
        • CareSource received notification on 9/1/10 that the other coverage terminated on 5/31/10.
        • Since the claim was originally processed within the 90 day period of receiving the notification that the primary coverage was terminated, CareSource would automatically adjust the claim.

        When CareSource Will NOT Automatically Adjust a Denied COB Claim:

        If the updated coverage was received after 90 days from the denial for COB, the provider still needs to notify CareSource within 365 days of date of service that the claim is COB. OR, the provider still needs to notify CareSource within 90 days from the date of the primary EOB denial, whichever is greater.


        Claim for date of service 12/1/09 was denied on 1/10/10 due to member having primary coverage effective 1/1/09, and the EOB was not attached to the claim.

        • CareSource received notification on 9/17/10 that the primary coverage terminated on 7/31/09.
        • Since the claim was denied for COB after 90 days of receiving notification that primary coverage was terminated, the claim would not be automatically adjusted.
        • However, if the provider contacts us by 12/1/10 or within 90 days of the EOB, the claim will be adjusted.

        Although CareSource is implementing this COB Adjustment Policy, it is still the provider's responsibility to review their accounts and submit COB claims in a timely manner for payment.

  • Extended timely filing requirements

  • General questions

    • How can I reach CareSource?
      • Call Provider Services at 1-800-390-7102, Monday through Friday, 8 a.m. to 5:30 p.m., except holidays. Follow the menu options to speak to a representative from the department you need.

    • How do I make a referral?
      • CareSource uses a paperless referral system to make it easy for PCPs to refer their patients to participating CareSource specialists. To make a referral, PCPs simply:

        • Document the referral in the member's medical chart. Please note the number of visits or length of time for each referral
        • Tell the member how to get the service
        • Notify the specialist of the referral

        Specialists document the referral in the member's chart as well. Referral forms are not required.

        For more information, please see Referrals and Prior Authorizations of the Provider Manual.

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