Medical Necessity Appeals
Standard Medical Appeals
Medical necessity appeals must be submitted within 90 days after the member or provider receives a letter from CareSource denying coverage. Appeals can be filed by a:
CareSource may request additional information from the provider to document medical necessity.
Providers may use the Medical Necessity Appeal Request Form to submit an appeal, but they are not required to. Medical necessity appeals should include:
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The member’s name, CareSource member ID number, and date of birth.
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The provider’s name and CareSource provider billing number.
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The type of service for which CareSource denied coverage, and the date and place when it was to be provided.
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The reason CareSource’s decision to deny coverage should be reconsidered.
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Any additional medical information to support your request.
Please submit medical necessity appeals to:
CareSource
One S. Main St.
Dayton, OH 45402
Attn: Claims Department -- Medical Necessity Appeal
All medical necessity appeals and associated information are reviewed by clinicians previously uninvolved with the case. CareSource will resolve appeals from members, or providers on behalf of members with written member authorization, within 15 days. All other standard medical necessity appeals will be resolved within 30 calendar days.
Expedited Medical Appeals
A provider may ask CareSource to expedite a medical necessity appeal if:
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The member is to be admitted to an inpatient facility.
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The member is within a continuing stay at an inpatient facility.
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The member has received emergency services but has not been discharged.
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The provider indicates that the time required for a standard appeal resolution could seriously jeopardize the member’s life, health or ability to attain, maintain or regain maximum function.
Providers may ask CareSource to expedite a medical necessity appeal by calling the service center at 1-800-488-0134 and following the appropriate menu prompts.
CareSource will decide whether to expedite the appeal within one working day. If CareSource decides to expedite the appeal, we will make a reasonable effort to promptly notify the member and provider by phone of our decision.
Once a medical necessity appeal has been expedited, CareSource will resolve it and verbally notify the member of the resolution within three working days or as expeditiously as the members’ medical condition requires. CareSource will verbally notify the provider or facility of the resolution if the member is in an inpatient setting. CareSource will also send written notification to both member and provider on the same business day of the decision.
If CareSource decides not to expedite the medical necessity appeal, we will notify the member and provider of that decision in writing within two days. CareSource will then follow the process and timeframes for standard medical necessity appeals.
CareSource will not penalize any member or provider in any way for appealing a medical necessity decision, or for asking us to expedite a medical necessity appeal.
Extension Requests
Members may verbally request that CareSource extend the timeframe to resolve any medical necessity appeal request up to 14 days. CareSource may also request an extension. CareSource must submit documentation that the extension is in the member’s best interest to the Ohio Department of Job and Family Services (ODJFS) for prior approval.
If ODJFS approves the extension, CareSource will notify the member in writing of the extension reason and new timeframe.