Prior Authorization-es
CareSource® evaluates 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 Pharmacy Prior Authorization Transparency Act Report to view this month’s statistics.
Please access the Prior Authorization Transparency Act Report to view this month’s statistics.
Prior Authorization Procedures
The Provider Portal is the preferred and faster method to request prior authorization for health care services. 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 portal please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal.
Alternate methods include phone, fax or mail.
Phone: 1-833-230-2155, Fax: 937-396-3802
Mail: CareSource
P.O. Box 1307
Dayton, OH 45401-1307
Nonparticipating Providers
Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions.
Emergency Services
All in-patient services require prior authorization. Please call 1-833-230-2155 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 provider.
To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please call 1-833-230-2155 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.
Please call 1-833-230-2155 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:
- MRI/MRAs
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.
Dental Prior Authorization
Starting plan year 2021, Marketplace dental providers can submit a dental authorization request via the DentaQuest Provider Web Portal.