Provider Disputes or Appeals

Definitions

CareSource provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Claim Disputes

If you believe the claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You should not file a dispute or appeal. Refer to the Claims page or the Navigate Provider Manual for further information related to claims submission.

Please note: All Non-participating providers should submit their claim issues as Claim Appeals and not as a Payment Dispute.

Process for Claim Disputes

Medicare providers who are in CareSource’s network and are participating for CareSource members must use the dispute process for any claim denials. Appeal rights do not exist for participating Medicare providers.

If you believe your claim was denied incorrectly or underpaid, you can submit a claim dispute.

Claim disputes must be submitted in writing. The dispute must be submitted within 60 calendar days of the date of denial or date of payment.

At a minimum, the dispute must include:

• Sufficient information to identify the claim(s) in dispute
• A statement of why you believe a claim adjustment is needed
• Pertinent documentation to support the adjustment

Incomplete requests will be returned with no action taken. Claim disputes can be submitted to CareSource through the following methods:

• Provider Portal (Preferred Method)
• Fax: 937-531-2398
• Mail: CareSource
  Attn: Provider Appeals
  P.O. Box 1947
  Dayton, OH 45401-1947

CareSource will render a decision within thirty calendar days of receipt. If the decision is to uphold the original claim adjudication, if you are a non-participating provider, you may appeal the decision. Appeals must be submitted within 60 days of the date of the denial.

Provider Appeals

Providers may request the following types of appeals:

• Claim appeals: Submit a claim appeal to request reconsideration of a claim denial.
• Clinical appeals: Submit a clinical appeal to request reconsideration of a medical necessity decision.

All appeal requests and associated information are reviewed by clinicians not previously involved with the case.

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to our Updates & Announcements page for notifications of changes that may impact your appeal.

Claim Appeals

If you are a non-participating provider, and if you do not agree with a denial on a processed claim, you have 60 calendar days to submit an appeal from initial adverse decision.

If the appeal is not submitted in the required time frame, with a statement of Good Cause, the claim will not be reconsidered, and the appeal will be dismissed. You will receive notification in writing if the appeal is denied. If your appeal is approved, your payment will appear on the Explanation of Payment (EOP).

Please note: If your issue is not related to a lack of authorization, please utilize the payment dispute process outlined above as your first method to resolve the issue.

Clinical Appeals

If you disagree with a clinical decision we have made regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from CareSource denying coverage, a provider or member can submit a pre-service or post-service clinical appeal. Clinical appeals are reviewed by nurses and physicians not involved in any prior review. They are also reviewed by practitioners with expertise and knowledge appropriate to the item, service, or drug being requested.

• Pre-Service Appeal: This is a denial of an authorization for a service prior to being completed. You have 60 days from the date of the receipt of the authorization denial, which is presumed to be five days from the date on the notice, to submit a standard pre-service appeal. This is considered a member appeal and will be resolved within 30 days plus any extension, if applicable, for a standard appeal. See the ‘Extending an Appeal” section for more information on extensions. Part B drug standard appeals will be resolved within seven days and may not be extended. CareSource will review documentation for Good Cause for late filing of an appeal. The pre-service appeal must be accompanied by a valid Authorization of Representative (AOR) form. The AOR form is available on our Forms page. Please note, an AOR form or equivalent is required if the appeal is submitted by anyone other than the member or provider with appealable interest for standard preservice appeals. Please see the ‘Expediting Clinical Appeals’ section for more information on expedited clinical appeals. Pre-Service appeals that are not approved by CareSource are forwarded to the Independent External Reviewer (IRE) by CareSource for Level 2 appeal, or in the event that CareSource does not make a timely decision.
• Post-Service Appeal: Participating providers should refer to the process for “Claim Disputes.” Non-participating providers may submit a claim appeal within 60 calendar days from the remittance notification date, which may include clinical review for medical necessity. Please refer to the ‘Non-Participating Provider Appeals and Disputes’ section for more information. Non-contract provider appeals that are not approved by CareSource are forwarded to the IRE by CareSource for Level 2 appeal, or in the event that CareSource does not make a timely decision.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must not submit a retro-authorization request prior to filing a clinical appeal, your issue is now considered a claim appeal and should be submitted as such.

The first appeal requested is called a Level 1 appeal. In this appeal, the coverage decision is reviewed to ensure we followed all the rules properly.

Providers can request a coverage decision or Level 1 appeal on a member’s behalf. If the appeal is denied at Level 1, it will be automatically forwarded to Level 2. Level 2 appeals are conducted by independent organizations not connected to us. For a provider to request any appeal after Level 2, the member must appoint the provider as his or her representative. Navigate Learn more about Appointing a Representative.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). Details of all levels can be found in the Navigate Provider Manual.

How to Submit Appeals

You can submit appeals through our Provider Portal or using the Navigate Standard Appeal Form. The Provider Portal is the most efficient method of submitting appeals.

Include the following required documentation:

• Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested.
• Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes
• If the service has already been provided, a copy of the original remittance advice and/or the denied claim
• If filing an appeal on behalf of a member or for pre-service issues, the valid Authorization of Representative form must accompany the appeal.

Expediting Clinical Appeals

If you feel the standard appeal timeframe of 30 days could seriously jeopardize the life or health of your patient, or their ability to regain maximum function, you may ask us to expedite a clinical appeal. CareSource does not take any punitive action against providers for supporting their patients’ expedited requests. You have 60 days from the date of the receipt of the authorization denial, which is presumed to be five days from the date on the notice, to submit an expedited appeal.

Documentation for Good Cause for late filing of an appeal will be reviewed. An AOR form or equivalent is required for expedited preservice appeals if submitted by anyone other than the member, or the member’s physician or staff of the physician’s office acting on the physician’s behalf. The AOR form is available on our Forms page.

CareSource will review the expedited request as expeditiously as the member’s medical condition requires. The appeal will be resolved with verbal notification reasonably attempted within 72 hours of receipt of the appeal by the grievance and appeal department, unless the timeframe is extended, or the appeal request does not meet expedited criteria.

If the appeal is approved, we will authorize or provide the service in this time frame and include with the notification information about the duration or limitations with approval. CareSource will send an appeal decision letter to the member and AOR, if applicable, as well as a copy to the provider within the 72-hour time frame.

If the appeal is denied or partially denied, CareSource will forward the case file to the IRE for Level 2 appeal, or in the event that CareSource does not make a timely decision. Please see “Denied Expedited Appeals” for more information about what happens if a request for expedited appeal review is denied, and “Extending an Appeal” for more information about extensions.

Please note, there is a limited amount of time to submit additional information for expedited clinical appeals. CareSource will outreach within 24 hours and work with the provider to obtain any needed information for the expedited appeal

Call us at 1-833-230-2176 to expedite a clinical appeal.

Denied Expedited Appeals

If CareSource decides not to expedite the clinical appeal because the criteria for expedited review is not met, CareSource will transfer the request to a standard appeal time frame beginning the day the expedited request was received. The member will be given prompt oral notice of the decision to not expedite including the member’s expedited grievance rights related to the decision not to expedite the request. A letter will also be sent to the member at the time of the decision, but not later than three calendar days of the verbal notice of the denial to expedite the request, notifying of the decision to not expedite the appeal, the appeal is being transferred the standard appeal time frame of 30 days, and will include the member’s expedited grievance rights and time frames, and the right to request an expedited appeal with provider support of serious jeopardy to life, health or function.

Extending an Appeal

Members may request that CareSource extend the time frame to resolve any medically necessity appeal request by up to 14 days. CareSource may also request an extension of up to 14 days, if the extension is in the member’s best interest. CareSource will notify the member in writing the reasons for the extension and inform the member of the right to file an expedited grievance if the member disagrees with the decision to extend the time frame. CareSource will issue its determination and authorize or approve the service if the appeal is approved, as expeditiously as the member’s health condition requires, but no later than upon the expiration date of the extension. Part B drug appeals may not be extended.

A Level 1 appeal may be withdrawn at any time before the decision is issued by filing a request with CareSource. The request to withdraw must be filed by the party who requested the appeal. If a request to withdraw is filed with CareSource, CareSource will dismiss the Level 1 appeal request. The request to withdraw may be written or verbal.

Now Available: Provider Fair Hearing Plan

The Provider Fair Hearing Plan is now available in a Navigate PDF version. Please review this document outlining the provider participation plan.

Updates & Announcements

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to our Updates & Announcements page for notifications of changes that may impact your appeal.

Contact Us

For any questions regarding CareSource’s processes, please contact Provider Services at 1-833-230-2176, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET).