Provider Disputes or Appeals

Definitions

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

Provider Dispute

Provider disputes are defined as outlined in OAC 5160-26-05.1 – PA A.6.f.i.2 as any provider inquiries, complaints or requests for reconsiderations ranging from general questions about a dispute to a provider disagreeing with a denial.

• They do not include inquiries that come through ODM’s Provider Web portal (HealthTrack).
• Provider disputes do include provider disagreements with the decision to deny, limit, reduce, suspend or terminate a covered service for lack of medical necessity that are subject to external medical review.

Peer-to-Peer

CareSource provides peer-to-peer reviews as an additional level of review for a pre- or post- service medical necessity denial.

Pre-Service Clinical Appeal

Appeals submitted related to denial of an authorization for a service prior to being completed.

Post-Service Clinical Dispute

Disputes submitted related to a denial of an authorization for a service that has already been completed.

Process for Provider Disputes

• Provider disputes can be submitted via CareSource Provider Portal, mail, fax or the CareSource Provider Services
  • • Provider Portal Login
    • CareSource Provider Call Center:  1-800-488-0134
    • Mail: CareSource P.O. Box 2008 Dayton, OH 45401-2008
    • FAX: 937-531-2398
• Providers may file a written dispute no later than 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely dispute submission, whichever is later.
• Submitted disputes should be documented on the  Navigate Provider Dispute Form
• Refer to the Provider Manual for further information related to disputes submission.

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 to our Utilization Review team for consideration. You may submit this online via the Provider Portal.

CareSource will resolve and provide written notice to the provider of the disposition of the dispute within 15 business days from the receipt of dispute for claim disputes, and 30 business days for disputes involving medical necessity. Written notice will not be provided if the dispute was resolved with an initial phone call or person-to-person contact.

Extending a Dispute

If additional time to resolve a claim dispute is needed past 15 business days then CareSource will provide a status update to the provider every five business days beginning on the 15^th business day until the dispute is resolved.

External Medical Review

Providers who disagree with CareSource’s determination on appeal to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity may request an External Medical Review with Permedion. Services denied, limited, reduced, suspended, or terminated for reasons other than lack of medical necessity and for which no clinical review was completed by CareSource are not subject to External Medical Review. The request for External Review must be submitted to Permedion within 30 calendar days of the date of the internal appeal notification. Providers must complete the “Ohio Medicaid MCE External Review Request” form located at www.hmspermedion.com (select Contract Information and Ohio Medicaid) and submit to Permedion together with the required supporting documentation including:

• Copies of all adverse decision letters from CareSource (initial and appeal)
• All medical records, statements (or letters) from treating health care providers, or other information that provider wants considered in reviewing case

Providers need to upload the request form and all supporting documentation to Permedion’s provider portal located at https://ecenter.hmsy.com/ (new users will send their documentation through secured email at IMR@gainwelltechnologies.com to establish portal access).

An external medical review is a written request for an independent review in which a provider may be unsatisfied with our decision to deny, limit, reduce, suspend or terminate a covered service for lack of medical necessity. NOTE: An internal appeal has to be completed before an External Medical Review request is submitted. Additionally, services that are denied for reasons other than lack of medical necessity (i.e. the service is not covered by Medicaid) are not subject to external medical review.

The external medical review process does not interfere with the provider’s right to request a peer-to-peer review, or a member’s right to request an appeal or state hearing, or the timeliness of appeal and/or state hearing resolutions.

Peer-to-Peer Process (Prior Authorization Denials Only)

CareSource provides the opportunity for providers to discuss the Utilization Management (UM) medical necessity determination of a denial or decrease in level of care with CareSource’s Medical Director/Behavioral Health Medical Director or designee within five business days of the notification of the determination. The peer-to-peer process is independent of the appeal process and does not impact the timeframe a member and/or provider has to appeal.

To initiate the peer-to-peer process, please call CareSource’s Utilization Management team at 1-833-230-2168.

Clinical Appeals (Prior Authorization Denials Only)

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, you may can submit a pre-service clinical appeal or post-service clinical dispute.

• Pre-Service Appeal: denial of an authorization for a service prior to being completed. You have 60 days from the date of the authorization denial to submit a pre-service appeal. Member consent is not required for preservice request. 
• Post-Service Clinical Dispute: denial of an authorization for a service that has already been completed. You have 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely submission, whichever is later. 

How to Submit Appeals

The most efficient way to submit appeals is through our Provider Portal. Other options include submittal of a Navigate Standard Appeal Form or an Navigate Expedited Appeal Form.

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 appeal/dispute.

Submit your appeals using the Navigate Standard Appeal Form and submit them via:

• Online: CareSource.com > Providers > Provider Portal Login > Ohio
• Fax: 937-531-2398
• Phone: 1-833-230-2101
  • Phone for Expedited Appeals: 1-800-488-0134
• Mail:

  CareSource
  Attn: Grievance & Appeals Department
  P.O. Box 2008 Dayton, OH 45401

Expediting Clinical Appeals

Per OAC 5160-26-08.4, CareSource shall establish and maintain an expedited review process to resolve appeals when the member requests and CareSource determines, or the provider indicates in making the request on the member’s behalf or supporting the member’s request, that the standard resolution time could seriously jeopardize the member’s life, physical or mental health or ability to attain, maintain, or regain maximum function.  Supporting documentation is required to justify the expedited request. Per OAC 5160-26-08.4, you must state how the member’s life, health, or return to maximum function would be seriously jeopardized if the appeal is not completed expeditiously.

Submit your request for an expedited clinical appeal on the Navigate Provider Expedited Appeal Form via either of the following:

• • Online: CareSource.com > Providers > Provider Portal Login > Ohio
  • Mail:           

    CareSource
    Attn: Grievance & Appeals Department
    P.O. Box 2008
    Dayton, OH 45401

Notification of Resolution on Expedited Requests

Appeals that are submitted by providers and meet the OAC 5160-26-08.4 definition of “expedited” will be resolved, and written notification via fax will be made within 48 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. CareSource will send written notification to the provider on the same day of the decision.

Denied Expedited Appeals

Per OAC 5160-26-08.4, CareSource shall establish and maintain an expedited review process to resolve appeals when the member requests and CareSource determines, or the provider indicates in making the request on the member’s behalf or supporting the member’s request, that the standard resolution time frame could seriously jeopardize the member’s life, physical or mental health or ability to attain, maintain, or regain maximum function.

If CareSource decides not to expedite the clinical appeal, we will send written notification of the appeal to the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. Provider appeals will be resolved within 10 calendar days from the date the appeal was received and follow the standard CareSource appeal process.

Extending an Appeal

CareSource must submit documentation that the extension is in the member’s best interest to the Ohio Department of Medicaid (ODM) for prior approval. If ODM approves the extension, CareSource will notify the member in writing of the extension reason and new timeframe.

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 1-800-488-0134, Monday through Friday, 7 a.m. to 8 p.m. Eastern Time (ET).