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

Process for Claim Disputes

Requests for adjustment for underpayment or overpayment may be submitted through the claim dispute process. You do not need to submit an appeal for this type of review. A request for review of a claim denial should be submitted as an appeal.

Claim disputes must be submitted in writing.

The dispute must be submitted within 90 calendar days of the date of payment.

At a minimum, the dispute must include:

1. Sufficient information to identify the claim(s) in dispute
2. A statement of why you believe a claim adjustment is needed
3. Pertinent document to support the adjustment

Incomplete requests will be returned with no action taken. The request must be resubmitted with all necessary information within 90 calendar days of the claim payment or 10 calendar days of the date on the letter notifying you of the incomplete request.

Claim disputes can be submitted to CareSource through the following methods:

• Provider Portal
• Mail:

  Claim Payment Dispute Address
  CareSource
  Attn: Quality Improvement
  P.O. Box 8738
  Dayton, OH 45401-8738

  Provider disputes for issues that are contractual or non-clinical should be sent to:
  CareSource
  Attn: Provider Relations
  P.O. Box 8738
  Dayton, OH 45401-8738

CareSource will render a claim dispute decision letter within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication, you may appeal the claim adjudication if timely filing rights still apply.

Claim Appeals

If you do not agree with the decision of the processed claim or dispute, you will have 365 calendar days from the date of service or discharge to file a claim appeal. If your claim appeal requires a review for medical necessity, please refer to the Clinical Appeals section.

If the appeal is not submitted in the required time frame, the claim will not be considered and the appeal will be denied. If the appeal is denied, providers will be notified in writing. If the appeal is approved, payment will show on the provider’s Explanation of Payment (EOP).

Please note: If you believe a claim processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file an appeal. Providers have 90 days from the date of service or discharge to submit a corrected claim. Refer to the Claims page or the Provider Manual for further information related to claims submission.

Clinical Appeals

If you disagree with a clinical decision 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.

• Pre-Service Appeal: Denial of an authorization for service prior to being completed. You have 180 calendar days from the date of notification of initial denial to submit a pre-service appeal. The pre-service appeal must be accompanied with a member’s written consent via the appointment of representative, must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member. For pre-service appeals submitted with written member consent, the standard appeal decision time frame is 30 business days after receipt of necessary information.
• Post-Service Appeal: Denial of an authorization for a service that has already been completed. You have 180 days from date of service, discharge or authorization denial to submit a post-service appeal. Member consent is not required for post service requests. The standard decision time frame for post-service provider appeals is 45 calendar days.

If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal.

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 member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. Please note: You can use the Navigate Consent for Provider to File an Appeal on Patient/Member’s Behalf form to record this consent.

If filing an appeal on behalf of a member or for pre-service issues the provider must be appointed by the member as their authorized representative which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. Please note: You can use the Navigate Internal Appeal Request form and the Navigate Appointment of Representative form to request the appeal and record this consent.

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 1-833-230-2101, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET).