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 Appeals
A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors. For out-of-network providers, please refer to the Non-Participating Provider Appeals and Disputes.
Claim Dispute
A dispute is the first formal review of the processing of a claim by CareSource (excluding denials based on medical necessity) and is typically submitted by participating providers. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial. CareSource pays non-contracted providers, as Medicare would have paid for the same service. If your disagreement is limited to the amounts a non-contracted provider could collect if the beneficiary were enrolled in original Medicare pursuant to § 422.214(a)(l), you should use the plan’s internal payment dispute process to:
CareSource
Attn: Provider Disputes
P.O. Box 1947
Dayton, OH 45401-1947
Clinical Appeals
A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the CareSource Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals, not submitted by a physician or a physician’s representative, must be accompanied by a valid Authorization of Representative form. For more information about requirements for pre- and post-service appeals, view the Clinical Appeals section below.
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 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
- Fax: 937-531-2398
- Mail: CareSource
Attn: Provider Appeals
P.O. Box 1947
Dayton, OH 45401
CareSource will render a decision within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication and you are a non-participating provider, you may appeal the decision. Appeals must be submitted within 60 days of the date of the denial.
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, without documentation of Good Cause, the claim will not be reconsidered, and the appeal will be dismissed. denied. 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).
Claim appeals will be resolved within 60 calendar days from the date of receipt.
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 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: 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 ‘Extending an Appeal” 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 ‘Expediting Clinical Appeals’ 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 “Non-Participating Provider Appeals and Disputes” 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 should 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. 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 Provider Manual.
Now Available: Provider Fair Hearing Plan
The Provider Fair Hearing Plan is now available in a 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).