![]() Member consent is not required for post service requests. You have 180 days from date of service, discharge or authorization denial to submit a post-service appeal. Post-Service Appeal: denial of an authorization for a service that has already been completed.The pre-service appeal must be accompanied with a member’s written consent, must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member. You have 60 days from the date of the authorization denial to submit a pre-service appeal. Pre-Service Appeal: denial of an authorization for a service prior to being completed.If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard.Īfter receiving a letter from CareSource denying coverage, a provider or member can submit a pre-service or post-service clinical appeal. To initiate the peer-to-peer process, please call CareSource’s Utilization Management team at 1-83. ![]() 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. Also, if a claim was denied for a missing consent for or other documentation, the information can be submitted using the Provider Portal and should not be submitted as an appeal.ĬareSource 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. ![]() Providers have 365 days from the date of service or discharge to submit a corrected claim. Please note: If you believe a claim processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. ![]() If the appeal is approved, your payment will appear on the Explanation of Payment (EOP). You will receive notification in writing if the appeal is denied. If you do not submit an appeal submitted in the required time frame, CareSource will not reconsider the decision, and the appeal will be denied. If you do not agree with a denial on a processed claim, you have 365 calendar days from the date of service or discharge, unless otherwise specified in your contract, to submit an appeal. If the decision is to uphold the original claim adjudication, you may appeal the claim adjudication decision if timely filing rights still exist. The request must be resubmitted with all necessary information within 90 calendar days of the claim payment or 10 calendar days of the date on the letter notifying you of the incomplete request.ĬareSource will render a claim dispute decision letter within 30 calendar days of receipt. Incomplete requests will be returned with no action taken.Pertinent documentation to support the adjustment.A statement of why you believe a claim adjustment is needed and the desired outcome.Sufficient information to identify the claims in dispute.At a minimum, the dispute must include:.The dispute must be submitted within 90 calendar days from the date of the explanation of payment (EOP) or provider remittance advise (PRA).Claim disputes must be submitted in writing.Please note: If the claim was denied for a missing consent form or other documentation, the information can be submitted using the Provider Portal and should not be submitted as a dispute. Refer to the Claims page or the Provider Manual for further information related to claims submission. You do not need to file a dispute or appeal. If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claims, you should submit a corrected claim.
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