Prior Authorization-es

CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.

Covered Services and Prior Authorization Requirements

Please access our covered services and prior authorization requirements to check what services require prior authorization. Please note that covered services and prior authorization requirements may differ between Healthy Indiana Plan and Hoosier Healthwise.

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 Procedures

The Provider Portal is the preferred and fastest 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: 1-844-607-2831

Fax: 1-844-432-8924

Mail:

CareSource
P.O. Box 1307
Dayton, OH 45401-1307

Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.

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 1-844-607-2831 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 1-844-607-2831 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.

Please call 1-844-607-2831 for any questions related to post-stabilization services.

Pharmacy Prior Authorization

Some drugs may require prior authorization before they will be covered. Please refer to the Pharmacy page to review these requirements.

For drugs processed through Express Scripts, please refer to the Formulary or Preferred Drug List (PDL) on the Drug Formulary page. For drugs processed through the medical benefit, please refer to the Procedure Code Lookup Tool and Authorization Requirements for Medications Under the Medical Benefit under Prior Authorization.

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, Medicaid dental providers can submit a dental authorization request via the SkyGen Portal.