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Frequently Asked Questions
Important News: We are pleased to welcome new CFC members to the CareSource Plan effective April 1, 2008. The increased membership will result in extremely high call volume during the transition period of March 24th through April 4th. As a reminder all eligibility verifications are serviced through our automated telephone system or on our website.
Claims status details for claims submitted within the last 45 days is available on our website, www.caresource-ohio.com and the pended claims reports that are mailed with the weekly check write.
- Hot Topics
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- General Questions
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- Billing
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- Claims
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- Appeals
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- Benefits
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- Authorizations
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- Member Eligibility
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- Website Questions
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General Questions
- What is CareSource?
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CareSource is a nonprofit Medicaid managed health care organization that serves consumers of:
- Covered Families and Children Medicaid
- Healthy Start and Healthy Families Medicaid
We contract with the Ohio Department of Job and Family Services (ODJFS) to provide services. Our focus is on prevention and partnering with local health care providers to offer the services our members need to remain healthy. [Back to top]
- What are the advantages of participating with CareSource?
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CareSource’s foundation is our strong partnership with our contracted health care providers. Because providers are so integral to the delivery of services, CareSource offers them a wide array of services and benefits, including:
- Prompt claims payment
- Claims call center
- Paperless referrals and low-hassle medical management
- Web-based transactions and electronic claims submission
- Provider relations staff
- Commitment to service
- Member support services
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- How can I become a participating provider?
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Call us toll free at 1-877-725-4577. We can give you the information you need to start the process of becoming a participating provider with CareSource. [Back to top]
- How can I reach CareSource?
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Call our service center toll-free at 1-800-488-0134, Monday through Friday, 7 a.m. to 7 p.m., except holidays. Follow the menu options to speak to a representative from the department you need. [Back to top]
- What services are available on the CareSource IVR?
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Our automated telephone service offers eligibility information for CareSource members 24 hours a day. To obtain automated eligibility for dates of service beginning today, or any day in the last 12 months, call the Provider Services Center and follow the “eligibility” menu options. Be sure to have the CareSource member ID and date(s) of service available. [Back to top]
- How do I make a referral?
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CareSource uses a paperless referral system to make it easy for PCPs to refer their patients to participating CareSource specialists. To make a referral, PCPs simply:
- Document the referral in the member’s medical chart. Please note the number of visits or length of time for each referral.
- Tell the member how to get the service.
- Notify the specialist of the referral.
Specialists document the referral in the member’s chart as well. Referral forms are not required.
For more information, please see How To Make a Referral. [Back to top]
Billing
- Can I ever bill my CareSource patients?
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State and federal regulations prohibit health care providers from billing CareSource members for services provided to them unless they agree in writing to pay for a specific service before it is rendered. And CareSource members are not responsible for any co-payments. Please see Member Billing Policy for full details. [Back to top]
- Members, or providers on behalf of members, have 180 calendar days after the services have been rendered to request a retrospective review (the process of reviewing and making a coverage decision for care or services that have already been) if a claim has not been submitted for the service.
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If a claim for payment of the non approved service has been submitted and denied for no authorization, members, or providers on behalf of members have 90 days from the date of issuance of the claim denial to request a retrospective review. A retrospective review will be completed within 30 calendar days from the receipt of the request. [Back to top]
- How do I submit a retro authorization?
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A retrospective can be faxed to the dedicated fax number of 1-888-527-0016 with the supporting clinical information. [Back to top]
- What is the turnaround time for a retro request?
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A retrospective review will be completed within 30 calendar days from the receipt of the request. [Back to top]
- Do you have a list of codes that require authorization?
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Currently we do not have an inclusive list of all procedure codes that require an authorization. [Back to top]
Claims
- How do I submit a claim?
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CareSource accepts paper and electronic claims. We encourage you to submit electronic claims for quicker processing. Please see How To Submit a Claim for more information. [Back to top]
- How can I optimize my claim payment timeframe?
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EDI claims are typically received and processed more quickly than paper claims. We require paper claim submission using the most current form version as designated by CMS, NUCC and the ADA. We cannot accept handwritten claims or SuperBills.
CareSource uses OCR/ICR (optical/intelligent character recognition) systems to capture claims information. This technology increases efficiency, improves accuracy and results in faster processing times.
Please adhere to the following requirements to ensure timely processing of your claim. Claims that do not meet these requirements may be significantly delayed in processing:
- Use only original claim forms. Do not submit claims that have been photocopied or faxed
- Fonts should be 10-14 point (capital letters preferred) with printing in black ink
- Do not use liquid correction fluid, stickers, labels or rubber stamps
- Ensure that printing is aligned correctly so that all data is contained within the corresponding boxes on the form
- Do not include handwritten information on the form
- Including your 12 digit CareSource provider ID allows for fastest paper claim processing
- In general, using clean claim forms with legible print will allow for more efficient processing
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- How soon will I know if my claim was paid?
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The majority of clean claims are processed within 30 days; we strive to process all claims received within 90 days. Payment notification is made via EOP (Explanation of Payment). You can also access this information from our website at www.caresource-ohio.com.
Because of the large volume of claims that CareSource receives and processes, we ask for your cooperation in allowing at least 45 days from submission date before calling about a claim status or submitting a duplicate claim. [Back to top]
- What options do I have to check more than three claim statuses at once?
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Claims status is one of many services available to our providers 24 hours a day through our secure provider web portal. The pended claims report is another resource for claims status and it is sent with the weekly check write. [Back to top]
- What is the filing limit with or without COB?
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Claims must be submitted to CareSource within 180 days of the date of service. When CareSource is the secondary payer, claims older than 180 days may be submitted to CareSource within 90 days of the date of primary carriers EOP. [Back to top]
Appeals
- How do I file an appeal?
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We hope you will be satisfied with CareSource and the service we provide. However, providers who are unhappy with CareSource’s action concerning a medical necessity decision or a claim payment may appeal it. Please see How To File an Appeal for more information. [Back to top]
Benefits
- Does CareSource offer extra benefits?
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Yes! CareSource offers its members many extra benefits and support services, such as a 24-hour nurse hotline and transportation to some health-related appointments. For more information, please see Extra Benefits. [Back to top]
- Can I ever bill my CareSource Medicaid patients?
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State and federal regulations prohibit health care providers from billing CareSource Medicaid members for services provided to them unless they agree in writing to pay for a specific service before it is rendered. CareSource Medicaid members are not responsible for any co-payments. Please see Member Billing Policy for full details. [Back to top]
Authorizations
- How do I obtain prior authorization?
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Providers can obtain prior authorization for health care services by contacting the CareSource Medical Management department by phone, fax, mail or e-mail:
- Online Prior Authorization
- By phone. Call 1-800-488-0134 and follow the menu prompts to speak to someone about prior authorization. There are separate options for pharmacy, dental and all other authorizations.
- By fax. Fax pharmacy requests to 1-866-930-0019. Fax all other requests to the CareSource medical management department at 1-888-752-0012.
- By mail. Send prior authorization requests to: CareSource, P.O. Box 1307, Dayton, Ohio 45401.
For more information, please see How to Request Prior Authorization. [Back to top]
- Is authorization needed for referrals to specialists?
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A referral is required for CareSource members to be evaluated or treated by most participating specialists. A prior authorization is needed to refer a member to an out-of-plan provider. Specialist-to-specialist referrals are generally not permitted. Care should be coordinated through the PCP. Please see Section 4 of the CareSource provider manual for more details. [Back to top]
- Is authorization needed for Outpatient diagnostic testing?
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Authorization for an outpatient diagnostic test by a participating provider is not required. [Back to top]
- Is authorization required for 23 hour observation?
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Authorization for an observation stay in a participating facility is not required. An observation in a non participating facility does require an authorization and must be reported to Medical Management for medical necessity review. [Back to top]
- Does CareSource require authorization if the member has primary insurance?
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Prior authorization is not required when CareSource is the secondary payer for medical services. Prior authorization is required for any dental request listed on the prior authorization list when CareSource is secondary. [Back to top]
Member Eligibility
- Why can’t I check the future eligibility for a member?
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All Medicaid recipients receive eligibility from the state on a month to month basis. Because of this, CareSource cannot be provided member eligibility for the upcoming months. [Back to top]
- Can a member be retro termed?
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Yes, a member’s eligibility can be retro termed at any point during the month by the Ohio Department of Job and Family Services (ODJFS). [Back to top]
- How do I check member eligibility?
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It is important to verify member eligibility before providing services. Patients must be eligible CareSource members at the time of service in order for services to be covered.
CareSource offers several ways to check member eligibility including by phone or here on our website. For more information, please see How To Check Member Eligibility. [Back to top]
- Can I see a member if my name is not on the member card?
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Yes! Any par PCP may see eligible CareSource members. PCP’s are responsible for verifying member eligibility before providing any services. Please log onto the provider web portal to confirm member eligibility, be advised eligibility does not guarantee payment of the claim. [Back to top]
Website Questions
- Is there a difference in the info I get if I sign up as a Provider or as a Group?
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There is no difference in the information you will receive. [Back to top]
- Why is the member id number I am using not pulling up the member?
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This error is generally caused by omitting the two zeros (00) necessary at the end of the member id. [Back to top]
- How can I reset my password if I don’t remember it?
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The primary user cannot reset their password. For assistance with resetting your password, please contact the Service Center at 1-800-488-0134. [Back to top]
- How can I add additional users?
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After logging into the portal, the primary user can add additional users through the manage users tab in the left navigation menu. [Back to top]
- What is an affiliation number?
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Your affiliation number is a unique identification number assigned to you by CareSource. This affiliation number can be found on your contract. [Back to top]
Website Questions
- Is there a difference in the info I get if I sign up as a Provider or as a Group?
-
There is no difference in the information you will receive. [Back to top]
- Why is the member id number I am using not pulling up the member?
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This error is generally caused by omitting the two zeros (00) necessary at the beginning of the member id. [Back to top]
- How can I reset my password if I don’t remember it?
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The primary user cannot reset their password. For assistance with resetting your password, please contact the Service Center at 1-800-488-0134. [Back to top]
- How can I add additional users?
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After logging into the portal, the primary user can add additional users through the manage users tab in the left navigation menu. [Back to top]
- What is an affiliation number?
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Your affiliation number is a unique identification number assigned to you by CareSource. This affiliation number can be found on your contract. [Back to top]
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