...Medical Director for further review and determination. Physician reviewers from CareSource of Carolina Co. are available to discuss individual cases with attending physicians upon request. Utilization review determinations are based...

f Clinical Practice Guidelines CareSource approves and adopts evidence-based nationally accepted standards and clinical practice guidelines to help inform and guide the provision of clinical care to members. CPGs are...

...The prescription is for an extended-release opioid. Drugs administered in the outpatient setting by a physician and billed under a member’s medical benefit may also require prior authorization. Refer to...

...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...

...and abuse situations. From the Office of the Inspector General The Office of the Inspector General (OIG) has created free educational materials to assist in teaching physicians about the federal...

...management A PCP shall provide: Availability of a personal physician to assist with coordination of a member’s overall care, as appropriate for the member Continuity of the member’s total health...

...will be answered by our Utilization Management department. Please call 1-833-230-2101 for any questions related to post-stabilization services. Advanced Imaging Prior Authorization Ordering physicians must obtain prior authorization for the...

Providers who wish to contract with CareSource® must first be credentialed. Through credentialing, we check the qualifications and performance of physicians and other health care practitioners. Providers are recredentialed a...

...performance of physicians and other health care practitioners. Providers are recredentialed a minimum of every three years and are considered to be recredentialed unless otherwise notified. Finish Onboarding Learn how...

...prior authorization for a specialty medication to be processed under the pharmacy benefit OR a physician administered drug to be processed under the medical benefit Medical and Other Prior Authorization...