Utilization Management

Utilization Management (UM) means CareSource reviews a request for certain health care services. The review can happen before, during, or after service. We will review the request for:

  • Medical necessity
  • Efficiency (Getting the concern addressed quickly)
  • Appropriateness of health care services
  • Treatment that our members get

Call us if you have questions about how we review your care. Call Member Services and ask to talk with someone on the UM team. When calling, please keep in mind:

  • UM is open for calls Monday – Friday from 8 a.m. to 5 p.m. Eastern Time. You may leave a message about UM issues after normal hours.
  • Visit CareSource.com to reach out to UM during and after normal hours.
  • Use the Tell Us form at CareSource.com/MemberInquiry.
  • A UM staff member who calls will say their name, title, and company (CareSource).
  • Staff are available to accept collect calls about UM issues.
  • Staff are accessible to callers who have questions about the UM process.

You can call us about:

  • UM for prior authorization (pre-approval) requests
  • Any other UM issues and concerns

We can also help members who speak other languages. Call us at 1-844-607-2829 (TTY: 1-800-743-3333 or 711).

How We Review Requests:

  • We use up to date clinical information and generally accepted guidelines to guide clinical decision making.
  • We do not reward health partners or our own staff for turning down coverage or services.
  • We do not offer financial rewards to our staff to make decisions that result in under-use of services.

New Care Approvals

CareSource may decide that a new development not currently covered by Medicaid will be a covered benefit. This includes newly developed:

  • Health care services
  • Medical devices
  • Therapies
  • Treatment options

Coverage is based on:

  • Updated Medicaid and Medicare rules
  • External technology assessment guidelines
  • Food and Drug Administration (FDA) approval
  • Medical literature recommendations

Member Services: 1-844-607-2829 (TTY: 1-800-743-3333), 8 a.m. to 8 p.m., Monday – Friday Eastern Time.