Request Prior Authorization

Prior Authorization Process

Providers can obtain prior authorization for health care services by contacting the CareSource Medical Management department by using our on-line form, phone, fax, mail or e-mail:

For Pharmacy Request

To request a prior authorization for a medication, please complete the form below and submit through our website, by phone, by fax or by mail.  If you are requesting a specialty medication (listed below), please use the corresponding prior authorization request form.

• Online Form. Pharmacy Online Prior Authorization Request Form
• 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. 

• Online Prior Authorization Request

When requesting a prior authorization, you will be asked to provide the following information:

• Member/patient name and CareSource member ID number.
• Provider name and CareSource provider billing number.
• Anticipated date of service.
• Diagnosis (by ICD-9-CM code and narrative).
• Procedure, treatment or service requested.
• Number of visits requested, if applicable.
• Reason for referring to an out-of-plan provider, if applicable.

If you are requesting inpatient admission (whether it is elective, urgent or emergent), please include:

• Admitting diagnosis and presenting symptoms.
• Plan of treatment.
• Anticipated discharge needs.

For inpatient surgery requests, please include:

• Date of surgery.
• Surgeon and facility.
• Admit date.
• Admitting diagnosis and presenting symptoms.
• Plan of treatment.
• Anticipated discharge needs.

For outpatient surgery requests, please include:

• Date of surgery.
• Surgeon and facility.
• Diagnosis.
• Procedure planned.
• Anticipated discharge needs.

Prior authorization is not based solely on medical necessity, but on a combination of medical necessity, medical appropriateness and benefit limitations.

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 for which prior authorization is required but not obtained.

For standard prior authorization/certification decisions, CareSource provides notice to the provider and member as expeditiously as the member’s health condition requires but no later than five working days following receipt of the request for service. Urgent decisions are made within 72 hours of receipt of request for service.