FAQs

Find answers below to common questions about how to work with CareSource.

Prior Authorization

  • How do I obtain prior authorization?

  • Is authorization needed for referrals to specialists?

    • A referral is required for CareSource members to be evaluated or treated by most participating specialists. A Prior Authorization is needed to refer a member to a non-participating provider. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the PCP. Please see the CareSource Provider Manual for more details.

  • Is authorization required for an observation?

    • Authorization for an observation stay in a participating facility is not required. An observation in a non-participating facility does require an authorization and must be reported to the Medical Management department.

  • Does CareSource require authorization if the member has primary insurance?

    • Prior authorization is not required when CareSource is the secondary payer for medical services.

      Prior authorization is required for any dental request listed on the prior authorization list when CareSource is the secondary payer.

  • How do I request a retrospective review?

    • Health Partners have 30 days from date of service or date of discharge, whichever is later, to request a retrospective review for medical necessity.

      The retrospective review request must include a copy of the carrier’s Explanation of Payment (EOP).

      All requests for services will be reviewed for timeliness and medical necessity.

      Health partners can request a retrospective review by contacting the Medical Management department at 1-800-488-0134 or by faxing the request to 1-888-527-0016. Clinical information supporting the request for services must accompany the request.

Timely Filing Requirements

  • What are the requirements for timely filing?

    • All CareSource claims that are clean with correct coordination of benefits will now be accepted 365 days from the date of service 
    • Claim appeals will be accepted 365 days from the date of service or discharge 
    • Medical necessity claims will be accepted for 180 days from the date or service, date of discharge or date of denial if service was not yet rendered

  • How is the filing period counted?

    • Days will be counted from the date of service or the discharge date, whichever is greater.

  • How much time does a health partner have to file if he/she makes an error when submitting a claim?

    • Health partners have 365 days from the date of service to submit a corrected claim. Identify the claim as “Corrected” when resubmitting to CareSource. 

  • Who do health partners contact with questions?

Provider Portal

  • Is there a difference in the information I receive if I sign up as a provider or as a group?

    • There is no difference in the information you will receive.

  • How can I reset my password if I don’t remember it?

    • The primary user cannot reset his or her password. For assistance resetting your password, please contact Health Partner Services at 1-800-488-0134.

  • How can I add additional users?

    • After logging into the Provider Portal, the primary user can add additional users through the “manage users” tab in the left navigation menu.

Eligibility

  • How do I check member eligibility?

    • It is important to verify member eligibility before providing services. Patients must be eligible CareSource members at the time of service in order for services to be covered.

      CareSource offers several ways to check member eligibility including by phone or here on our website.

      Phone: 1-800-488-0134
      Provider Portal Available 24/7

      For more information, please see How To Check Member Eligibility.

  • Why can’t I check future eligibility of a member?

    • All Medicaid recipients receive eligibility from the state on a month-to-month basis. Because of this, CareSource cannot be provided member eligibility for the upcoming months.

  • Can a member be retro termed?

    • Yes, a member’s eligibility can be retro termed at any point during the month by the Ohio Department of Medicaid (ODM).

  • Can I see a member if I am not his or her assigned PMP?

    • Yes! Any participating PCP may see eligible CareSource members. PCP’s are responsible for verifying member eligibility before providing any services. Please log onto the Provider Portal to confirm member eligibility. Please note, eligibility does not guarantee payment of the claim.

Appeals

  • How do I file an appeal?

    • We hope you will be satisfied with CareSource and the service we provide. However, health partners who are unhappy with CareSource’s action concerning a medical necessity decision or a claim payment may appeal it. Please see our Appeals page for more information.

  • What if a health partner appeals and the claim is still denied?

    • Appeals that have gone through the formal appeal process are deemed to be final.

  • What if CareSource makes an error in how the claim was paid?

    • Providers have 365 days from the date of service to notify CareSource. The 365 day timeframe should give ample time to cite references and documentation regarding the error.

      Please see the Appeals page for more information.

Claims

  • How do I submit a claim?

    • CareSource accepts paper and electronic claims. We encourage you to submit electronic claims for quicker processing. Please see the Claims page for more information.

      Ohio health partners have 365 days from the date of service to submit claims.

  • How can I optimize my claim payment timeframe?

      • Claims submitted electronically are typically received and processed more quickly than paper claims. Health partners may submit claims electronically through the CareSource Provider Portal or through electronic data interchange (EDI) clearinghouses specified by CareSource. For paper claim submissions, we require the most current form versions as designated by the Centers for Medicare & Medicaid Services (CMS), National Uniform Billing Committee (NUBC) and the American Dental Association (ADA). We cannot accept handwritten claims or superbills.

        Tips for Submitting Paper Claims:

        • Use only original claim forms. Do not submit claims that have been photocopied or faxed.
        • Fonts should be 10-14 point (capital letters preferred) with printing in black ink.
        • Do not use liquid correction fluid, stickers, labels or rubber stamps.
        • Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form.
        • Do not include handwritten information on the form.
        • We recommend including your 12 digit CareSource provider ID, which allows for fastest paper claim processing.
        • In general, using clean claim forms with legible print will allow for more efficient processing.

    • How soon will I know if my claim was paid?

      • The majority of clean claims are processed within 30 days; we strive to process all claims received within 90 days. Payment notification is made via Explanation of Payment (EOP).

        Because of the large volume of claims that CareSource receives and processes, we ask for your cooperation in allowing at least 45 days from submission date before calling about a claim status or submitting a duplicate claim.

    • How do I check pended claims?

      • Claims status is one of many services available to our providers 24 hours a day through our secure Provider Portal. The pended claims report is another resource for claims status and it is sent biweekly.

Billing

  • Can I ever bill my CareSource patients?

    • State and federal regulations prohibit health care providers from billing CareSource members for services provided to them except under specific circumstances. Please remember that regulations state that health care providers must hold members harmless in the event that CareSource does not pay for a covered service performed by a provider unless CareSource denies prior authorization of the service. In this instance, the provider must notify the member in writing that the member is financially responsible for the specific service. This must be completed prior to providing the service and the member must sign and date the notification. CareSource members are not responsible for any co-payments on Medicaid services. Please see the Member Billing Policy for full details.

Coordination of Benefits

  • How do I determine which plan is the primary payer?

    • Medicaid is the payer of last resort, by Federal statute (42 U.S.C. 1396a(25), 1396b(d)(2), and 1396b(O)). Other identified insurance always becomes primary and must be exhausted before seeking reimbursement from Medicaid or Medicare Managed Care Plans. The only exception is BCMH (Bureau for Children with Medical Handicaps), where Medicaid would be considered primary.

  • How do I know if a member has other coverage?

    • It is the responsibility of the health partner to verify and obtain all Coordination of Benefits (COB) information at the time of service.

      There are two ways to verify:

      • Online: Visit the Provider Portal to view the COB information that CareSource has on file for the member.
      • By phone: Call 1-800-488-0134 and follow the menu prompts.

  • How do I submit Coordination of Benefits?

    • Coordination of Benefits (COB) claims can be submitted by mail or electronically.

      COB claims should be submitted by mail with the Explanation of Benefits and sent to:

      CareSource
      P.O. Box 8730
      Dayton, OH 45401-8730

      For electronic COB claim submissions, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information.

  • Can I submit Coordination of Benefits claims electronically?

    • Yes! CareSource can accept Coordination of Benefits (COB) claims electronically. CareSource accepts both professional claims (CMS-1500) and hospital/facility claims (UB-04) electronically. CareSource’s dental claims are managed through Scion, which accepts electronic dental claims through clearinghouses and the Scion Portal. We recommend that dental health partners submit claims using ADA forms.

  • How do I submit Coordination of Benefits claims electronically?

    • When submitting Coordination of Benefits (COB) claims electronically, please refer to your clearinghouse, trading partner or billing administrator and complete all required COB information. For professional claims (CMS-1500), COB information should be sent at the line level. For hospital/facility claims (UB-04), COB information should be sent at the claim level. In addition to the required COB information, you must send other carrier paid amounts and all claim/line level adjustment group codes, reason codes, remark codes and payment amounts.

  • Will my claim be rejected if the primary insurance filing timeframes differ from CareSources’s timely filing guidelines?

    • If you are not able to submit a claim according to our filing deadline of 365 days, we will accept 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater. Simply submit a copy of the primary carrier’s EOB to CareSource.

  • What Coordination of Benefits information must be submitted?

    • For secondary electronic (EDI) professional and institutional claims, the following Coordination of Benefits (COB) information must be submitted:

      • Primary Payer Paid Amount: Submit the primary/COB paid amount for each claim reported on the 835 payment or as identified on the explanation of payment (EOP).
      • Adjustment Group Code: Submit other payer claim adjustment group codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered service group codes.
      • Adjustment Reason Code: Submit other payer claim adjustment reason codes as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services or HIPAA codes.
      • Adjustment Amount: Submit other payer claim adjustment amounts as reported on the 835 payment or as identified on the EOP, such as deductible, coinsurance, copayment, contractual obligations and/or non-covered services payments.

  • Where do I include Coordination of Benefits information?

    • For secondary professional or institutional claims to be paid electronically, all Coordination of Benefits (COB) information must be submitted in the applicable loops and segments. Loops include:

      • Loop ID – 2320: Other Subscriber Information
      • Loop ID – 2330A: Other Subscriber Name
      • Loop ID – 2330B: Other Payer Name
      • Loop ID – 2330: Other Provider Information
      • Loop ID – 2430: Line Adjudication Information (for professional claims)

  • If I receive a denial for not supplying Coordination of Benefits, what do I need to do?

    • Submit a copy of the Explanation of Benefits (EOB) by email, fax or mail:

      You can also submit the claim and EOB electronically. Please refer to your clearinghouse, trading partner or billing administrator to complete this process.

  • What if I receive a denial for COB and the member’s primary coverage is no longer effective?

  • What if the Provider Portal is missing information, such as the group number or member’s date of birth?

    • Check the carrier’s website or call the carrier directly to obtain the information. We encourage all health partners to verify the patient’s insurance coverage at the time of service.

  • What are the timely filing guidelines for Coordination of Benefits?

    • 365 days from the date of service or 90 days from the primary carrier’s Explanation of Benefits date, whichever is greater.

  • If I receive a denial showing the member has other coverage, how can I get the other coverage information?

    • Online: You can obtain the other coverage information that CareSource has on file by reviewing the member’s eligibility information on our Provider Portal.

      By phone: Call 1-800-488-0134 and follow the menu prompts.

  • What if I received a letter about a takeback/recoupment indicating that the member has primary insurance?

    • There are two sources where takeback/recoupment information may come from:

      1) Health Management Systems (HMS)
      HMS is our third party vendor that identifies if a patient has a primary insurance.

      Please send documentation to HMS within 30 days of the recoupment letter. Documentation is typically an EOB showing coverage was not in effect, services were paid or services were denied.

      Third Party Recovery Unit
      Attn: CareSource COB Project HMS, Inc.
      5615 High Point Drive
      Suite 100
      Irving, TX 75038
      (877) 259-3308
      Fax: (314) 905-2064

      2) Recoupment/Takebacks from CareSource
      CareSource will initiate an automatic recoupment in 30 days from the date of notification. If you are disputing the information, send supporting documentation directly to CareSource within 60 days of the recoupment letter date. Documentation is typically an EOB showing coverage was not in effect, services were paid or services were denied.

      CareSource COB
      P.O. Box 8730
      Dayton, OH 45401-8730

  • Should I send a check when I receive the recoupment notification?

    • No, you do not need to send a refund check or initiate an adjustment request on these claims unless notified otherwise. The recoupment will be made against future claims payment and will show on the Explanation of Benefit.

  • What if the primary carrier denies a claim for procedural reasons or if the member is not supplying requested information needed to pay the claim?

    • CareSource needs a copy of the primary carrier’s Explanation of Benefits denying the claim in order to process the claim within 365 days of our timely filing guidelines:

      • The member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire).
      • Procedural denial reasons (e.g., timely filing, prior authorization, no referral from primary care provider).

  • Are there cases where I would receive an adjustment when a COB claim originally denied?

    • When CareSource Will Automatically Adjust a Denied Coordination of Benefits (COB) Claim:

      CareSource will automatically adjust the claims that originally denied for COB when the following criteria are met:

      • Primary insurance has been updated retroactively to show coverage terminated AND
      • The claim was denied for COB within 90 days of receiving the updated information that the primary coverage has been terminated

      Example:

      • Claim for date of service 6/15/16 was denied on 7/10/16 due to the member having primary coverage effective 1/1/16.
      • CareSource received notification on 9/1/16 that the other coverage terminated on 5/31/16.
      • Since the claim was originally processed within the 90 day period of receiving the notification that the primary coverage was terminated, CareSource would automatically adjust the claim.

      When CareSource Will NOT Automatically Adjust a Denied COB Claim:

      If the updated coverage was received after 90 days from the denial for COB, the provider still needs to notify CareSource within 365 days of date of service that the claim is COB. OR, the provider still needs to notify CareSource within 90 days from the date of the primary EOB denial, whichever is greater.

      Example:

      Claim for date of service 12/1/15 was denied on 1/10/16 due to member having primary coverage effective 1/1/15, and the EOB was not attached to the claim.

      • CareSource received notification on 9/17/16 that the primary coverage terminated on 7/31/15.
      • Since the claim was denied for COB after 90 days of receiving notification that primary coverage was terminated, the claim would not be automatically adjusted.
      • However, if the provider contacts us by 12/1/16 or within 90 days of the EOB, the claim will be adjusted.

      Although CareSource is implementing this COB adjustment policy, it is still the health partners’ responsibility to review their accounts and submit COB claims in a timely manner for payment.

  • How does COB work when CareSource is a secondary payer for obstetrician deliveries?

    • CareSource will deny all prenatal office visits when the explanation for Coordination of Benefits (COB) information needed has not been provided. After the primary Explanation of Benefits (EOB) is received, CareSource will verify if the prenatal visits are a part of the primary payer’s global reimbursement. If they are, CareSource will make no payment until a delivery charge is received. If the prenatal visits are excluded by the primary payer (e.g., maternity benefits not covered by the plan), CareSource will process the claim as if CareSource was the primary payer.

      After the delivery charge is received, CareSource will combine all prenatal visit charges with the delivery charges. CareSource will subtract the primary payer’s payment from the Medicaid allowable amount (the benefit allowance for all visits and the delivery charge) and will pay any remaining CareSource allowable payment.

      Global Obstetrical Codes are Not Recognized

      If the first claim that CareSource receives is for a global delivery, the claim will deny for invalid coding. The provider will need to re-bill, within 90 days of the denial or 365 days from the date of service, using the delivery only CPT codes, since CareSource does not recognize global obstetrical codes for claims processing.

      After the delivery charge is received, CareSource will determine the Medicaid allowed amount and then subtract the primary insurance paid amount. CareSource will pay any remaining liability up to the Medicaid allowed amount. CareSource will not pay more than the CareSource normal benefit when no other coverage exists.

      For obstetrician delivery claims, CareSource will not require the primary payer’s EOB charges to match the charges on the claims submitted to CareSource.

  • What if the primary payer denies for non-cooperative parent/procedural reasons?

    • CareSource will require a copy of the primary carrier’s Explanation of Payment (EOP) denial in order to process the claim as primary when claims are denied by the primary carrier for the following reasons:

      • Member did not supply the requested information (e.g., accident/injury questionnaire, full-time student questionnaire)

      • Procedural denial reasons (e.g., timely filing, prior authorization, referral from primary care provider)

  • How will CareSource pay claims when the primary insurance’s allowed amount is less than the CareSource allowed amount?

    • After the primary insurance pays, CareSource will pay the remainder, up to the lessor of the allowed amounts.

General Questions

  • What is CareSource?

    • CareSource is a nonprofit managed health care organization that serves Medicaid, Marketplace and Medicare consumers; including families with low incomes, children, pregnant women and people who are aged, blind or have disabilities. Ohio Medicaid also includes Healthy Start and Healthy Families.

      We contract with the Ohio Department of Medicaid (ODM) to provide services. Our focus is on prevention and partnering with local health care providers to offer the services our members need to remain healthy.

  • What are the advantages of participating with CareSource?

    • CareSource’s foundation is our strong partnership with our contracted health partners. Because health partners are so integral to the delivery of services, CareSource offers them a wide array of services and benefits, including:

      • Prompt claims payment
      • Claims call center
      • Paperless referrals and low-hassle medical management
      • Web-based transactions and electronic claims submission
      • Secure Provider Portal available 24/7 where health partners can perform a variety of functions, including checking eligibility and claim status, submitting prior authorizations and more 
      • Provider relations staff
      • Commitment to service
      • Member support services

  • How can I become a participating health partner?

    • Health partners can visit our Plan Participation page to learn how to contract with CareSource. Or, call Provider Services at 1-800-488-0134 and we can give you the information you need to start the process of becoming a participating health partner.

  • How can I reach CareSource?

    • Call Provider Services at 1-800-488-0134, Monday through Friday, 8 a.m. to 8 p.m., except holidays. Follow the menu options to speak to a representative from the department you need.

  • How do I make a referral?

    • CareSource uses a paperless referral system to make it easy for primary care providers (PCPs) to refer their patients to participating CareSource specialists. To make a referral, PCPs simply:

      • Document the referral in the member’s medical chart. Please note the number of visits or length of time for each referral.
      • Tell the member how to get the service.
      • Notify the specialist of the referral.

      Specialists document the referral in the member’s chart as well. Referral forms are not required.

      For more information, please visit the Referrals and Prior Authorizations section of the Provider Manual.

    If you have questions, we are here to help you find answers. Visit the Contact Us page to help us direct you to the correct area.