Prior Authorization
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.
Prior Authorization Submission Options
The Provider Portal is the preferred and faster method to request prior authorization for health care services. You can receive immediate approval and also review the status of an authorization.
| Method | Contact Info |
|---|---|
Provider Portal (Preferred) | If you need assistance with submitting your prior authorization or have questions regarding submissions via the 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 | |
CareSource |
Written prior authorization requests should be submitted on the Prior Authorization Request Form.
Non-Participating Providers
Prior authorization must be obtained before sending patients to non-participating providers, with the following exceptions.
Emergency Services
All in-patient services require prior authorization. Please call 1-833-230-2101 to obtain prior authorization for emergency admissions. Outpatient emergency services do not require prior authorization.
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting by a participating provider.
To request prior authorization for observation services as a nonparticipating provider or to request authorization for an inpatient admission, please call 1-833-230-2101 and follow the appropriate menu prompts. During regular business hours, your call will be answered by our Utilization Management department.
Please call 1-833-230-2101 for any questions related to post-stabilization services.
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.
Turning Point Partnership for Cardiac and Musculoskeletal Surgical Procedures
CareSource partners with TurningPoint to cover Cardiac and Musculoskeletal Services for our CareSource members.
Please refer to the Procedure Code Lookup Tool to check whether a service requires prior authorization from TurningPoint.
| West Virginia Marketplace TurningPoint Contact Information | |||
|---|---|---|---|
Local Phone | Toll Free Phone | Local Fax | Toll Free Fax |
Learn more information by visiting the TurningPoint website.
Dental Prior Authorization
Starting plan year 2021, Marketplace dental providers can submit a dental authorization request via the DentaQuest Provider Web Portal.
Peer-to-Peer Process
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 seven 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.
Peer-to-peer rights are separate and distinct from your clinical appeal rights. If you received an authorization denial, your peer-to-peer rights were provided in your denial letter from CareSource. Please refer to your denial letter to exercise your available peer-to-peer rights. CareSource provides peer-to-peer reviews as an additional level of review for your pre- or post-service medical necessity requests. If a peer-to-peer is requested, it must be completed prior to you submitting a clinical appeal.
To initiate the peer-to-peer process, please call CareSource’s Utilization Management team at 1-833-230-2168.