Utilization Management

CareSource is committed to maintaining the quality and appropriateness of health care services provided to our members. The Medical Management department performs all utilization management (UM) activities including prior authorization, preservice review, urgent concurrent review, post service review, filing an appeal, discharge planning, and other activities. CareSource makes its UM criteria available in writing by mail, fax, phone or on this webpage.

• Mail: CareSource, Attn: Medical Management Dept., P.O. Box 1307, Dayton OH 45401
• Fax: 844-676-0370

On an annual basis, CareSource completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

Prior Authorization

CareSource understands that you may have questions about prior authorization. Please visit our Prior Authorization webpage.

Transition of Care

CareSource will coordinate continuity of care for members who have existing care treatment plans that include scheduled services with non-participating health partners or who transition to or from another payer including those members identified as having special health care needs. For continuity of care request approvals for non-participating primary care providers, 30 days of service will be allowed for the non-participating health partner to transfer care to the network primary care provider.

The provider will have to provide evidence of the authorization of the services from GAMMIS or the method you received verification of services. CareSource will provide an authorization from the date of eligibility with CareSource to the end of the already approved service. The provider will have to submit a request for any additional services for review of medical necessity outside these dates of service prior to transition.

Yes, CareSource will need to be contacted via phone at 1-855-202-1058, fax at 1-844-676-0370, or email at gamedmgt@caresource.com as there needs to be an authorization in our system that matches the billed services.

Medical Necessity Criteria

CareSource utilizes nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. CareSource defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. CareSource also has policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a CareSource Medical Director for further review and determination. Physician reviewers from CareSource are available to discuss individual cases with attending physicians upon request.

Utilization review determinations are based only on appropriateness of care and service and existence of coverage. CareSource does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

Our members’ health is always our number one priority. Upon request, CareSource will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling or faxing the CareSource Medical Management Department. If you would like to discuss an adverse decision with physician reviewer, please call the Medical Management department at 1-855-202-1058 within five business days of the determination.

Access to Staff

Providers may call our toll-free number at 1-855-202-1058 to contact Medical Management staff with any UM questions.

• Staff members are available from 8 a.m. to 5 p.m. Eastern Time (ET), Monday through Friday, for inbound calls regarding UM issues.
• Staff members can receive inbound communication regarding UM issues after normal business hours.
• Providers may leave voice mail messages on these telephone lines after business hours, 24 hours a day, 7 days a week.
• Medical necessity determination requests can be submitted 24 hours a day, seven days a week via a dedicated fax line and the Provider Portal.
• Staff members can send outbound communication regarding UM inquiries during normal business hours, unless otherwise agreed upon.
• Staff members are identified by name, title and organization name when initiating or returning calls regarding UM issues.
• Staff members are available to accept collect calls regarding UM issues.
• Staff members are accessible to callers who have questions about the UM process.

In the best interest of our members and to promote their positive health care outcomes, CareSource supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.

Member Support Services

Representatives are available to answer member questions regarding UM.

• Representatives are available by telephone Monday through Friday, except on the following holidays in in 2023: New Year’s Day (Jan. 2, 2023), Martin Luther King Jr. Day – observed (Jan. 16, 2023), Memorial Day (May 29, 2023), Independence Day (July 4, 2023), Labor Day (Sept. 4, 2023), Thanksgiving Day (Nov. 23, 2023), Day after Thanksgiving (Nov. 24, 2023), Christmas Eve – observed (Dec. 22, 2023), Christmas Day (Dec. 25, 2023).
• CareSource offers language interpreters for members who need assistance to communicate with CareSource to discuss UM issues. These services are available at no cost to the member. As a provider, you are required to identify the need for interpreter services for your CareSource patients and offer assistance to them appropriately.