Prior Authorization
We evaluate prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires 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 provider.
Prior Authorization Statistics
- Please access the Interoperability Prior Authorization Report to view the latest statistics.
Prior Authorization Submission
Per West Virginia law, prior authorization submissions must be completed via the Provider Portal. With this method, you can receive immediate approval and also review the status of an authorization.
If you need assistance with submitting your prior authorization or have questions regarding submissions via the Provider Portal, please reach out in either of the following ways:
- Email CiteAutoAssistance@caresource.comand a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal.
- Call Provider Services for assistance at 1-833-230-2101. Hours of operation are Monday through Friday from 8 a.m. to 6 p.m. Eastern Time (ET).
Non-Participating Providers
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:
| Service Type | Contact Information |
|---|---|
Emergency All in-patient services require prior authorization. Outpatient emergency services do not require prior authorization. | |
Post Stabilization 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 provider. |
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- MRI/MRAs
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from Evolent for imaging procedures at RadMD’s website.
Turning Point Partnership for Cardiac and Musculoskeletal Surgical Procedures
CareSource partners with TurningPoint to cover Cardiac and Musculoskeletal Services for our CareSource members.
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization from TurningPoint.
| West Virginia Marketplace TurningPoint Contact Information | |||
|---|---|---|---|
| Local Phone | Toll Free Phone | Local Fax | Toll Free Fax |
| 304-603-4673 | 855-578-7350 | 304-553-7061 | 844-472-0481 |
Learn more information by visiting the TurningPoint website.