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.

• Navigate Prior Authorization List

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: 1-844-679-7865
• Outpatient/Inpatient Elective Fax: 844-417-6157
• Emergency Inpatient Admissions Fax: 937-487-1664
• SNF Fax: 844-417-6157
• Mail: CareSource
  P.O. Box 1307
  Dayton, OH 45401-1307

Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form (coming soon).

Nonparticipating Providers

Prior authorization must be obtained before sending patients to nonparticipating providers, with the following exceptions:

Emergency Services

Use of emergency services does not require authorization. Admissions that result from emergency room visits do require authorization. Please call 1-833-230-2176 to obtain prior authorization for emergency admissions.

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 844-679-7865 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.

Please call 1-833-230-2176 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.