Prior Authorization
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CareSource® evaluates prior authorization requests based on medical necessity, medical appropriateness and benefit limits.
Services That Require Prior Authorization
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization. All services that require prior authorization from CareSource should be authorized before the service is delivered. CareSource is not able to pay claims for services in which prior authorization is required, but not obtained by the provider.
Pharmacy Prior Authorization
CareSource requires you to get prior authorization for certain drugs. This means that you will need to get approval from CareSource before the prescription is filled. If you don’t get approval, CareSource may not cover the drug. Discover more on our Pharmacy page.
Prior Authorization Submission Options
| Method | Contact Info |
|---|---|
Provider Portal | If you need assistance with submitting your prior authorization or have questions regarding submissions via the Provider Portal, please email CiteAutoAssistance@caresource.com and a representative will be in contact. This email is only for assistance and questions regarding prior authorizations within the Provider Portal. |
Phone | |
Fax | Outpatient/Inpatient Elective Fax: Emergency Inpatient Admissions Fax: SNF Fax: |
CareSource |
Written prior authorization requests should be submitted on the Medical Prior Authorization Request Form.
Non-Participating Providers
Prior authorization must be obtained before sending patients to non-participating providers, with the following exceptions:
| Service Type | Contact Information |
|---|---|
Emergency | 1-833-230-2176 |
Post-Stabilization | 1-833-230-2176 |
Advanced Imaging Prior Authorization
Ordering physicians must obtain prior authorization for the following outpatient, non-emergent diagnostic imaging procedures:
- MRI/MRAs
- CT/CTA scans
- PET scans
Ordering providers can obtain prior authorization from NIA for imaging procedures at RadMD’s website.