...laws. The medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. CareSource is not responsible for,...

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here. # A B C D E F G H I...

...Determinations Medical Necessity Determinations Medical Necessity Determinations Medical Necessity Determinations Medical Necessity Determinations Medical Necessity for Medical Benefit Medications Medical Necessity for Non-Formulary / Non-Preferred Medications Medical Necessity for Non-Formulary...

...– $10 copay Specialist $0 – $50 copay $0 – $35 copay Other Medical Benefits (In-Network) Inpatient Hospital Care Days 1-5: $380 per day Days 6-90: $0 copay per day...

...the University of Pittsburgh School of Medicine. He is a member of many professional societies including the American College of Physicians, the American Medical Association and the National Medical Association....

...member of our plan you must use network providers to get your medical care and services. View Chapter 3 Using the plan for your medical and other covered services in...

Organization Determinations (Decisions) A decision we make about the coverage of a service. If you believe you are entitled to a medical service (Part C or Medicaid) you can request...

...quality issue reviews. Medical record requests are forwarded to providers via mail, e-mail or fax and may be returned to CareSource via these same mechanisms as detailed in the medical...

...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...

...will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CareSource Medical Management Department. If you would...