CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness and benefit limits.
Services that Require Prior Authorization
All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the health partner.
Prior Authorization Procedures
Request prior authorizations for health care services by contacting the CareSource Medical Management department by phone, fax, mail or email.
P.O. Box 1307
Dayton, OH 45401-1307
Written prior authorization requests should be submitted on the Ohio Provider Medical Prior Authorization Request Form.
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions.
All in-patient services require prior authorization. Please call 1-800-488-0134 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.
Post Stabilization Services
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating health partner.
To request prior authorization for observation services as a nonparticipating health partner or to request authorization for an inpatient admission, please call 1-800-488-0134 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Medical Management Department.
Please call 1-800-488-0134 for any questions related to post-stabilization services.
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- CT/CTA scans
- PET scans
Ordering health partners can obtain prior authorization from NIA for imaging procedures at RadMD’s website or by calling 1-800-424-5600 and following the appropriate menu options.
DENTAL PRIOR AUTHORIZATIONS
Dental providers can submit a prior authorization via the dental web portal.