![]() Notification of ResolutionĬareSource will decide whether to expedite an appeal within 48 hours/two (2) days. If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal.Ĭall us at 1-84 to request an expedited clinical appeal. Expediting Clinical AppealsĬareSource shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member. If you have not received an authorization denial from the CareSource Utilization Management Department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal. A 14 calendar-day extension may be requested by CareSource on any provider appeal. The standard decision time frame for post-service provider appeals is 30 calendar days. Member consent is not required for post service requests. Denial of an authorization for a service that has already been completed: You have 60 days from date on the notice of action, discharge or authorization-denial to submit a post-service appeal.A 14 calendar-day extension may be requested by CareSource. ![]() For pre-service appeals submitted with written member consent, the standard appeal decision time frame is 30 calendar days from the date of receipt by CareSource. Denial of an authorization for a service prior to being completed: You have 60 calendar days from the date of action notice to submit a pre-service appeal.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. The binding arbitration process must be conducted in accordance with the rules and regulations of the American Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as adopted in the State of Indiana at IC-34-57-2-2. Through the Provider Portal (most efficient method) or the Standard Appeal FormĬlaims appeals filed without first submitting a dispute will not be processed.Īrbitration Process: If you are dissatisfied with the decision of the claim appeal, you may submit the matter to binding arbitration. ![]() Within 60 days of the resolution of the dispute process.Providers must exhaust the claim dispute process as outlined above before filing a claim appeal. Please note: You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form to record this consent. If filing an appeal on behalf of a member or for pre-service issues, the member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member.If the service has already been provided, a copy of the original remittance advice and/or the denied claim.Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes.Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed and the reason service is being requested.Include the following required documentation: Must be completed before requesting a claim appealĪll appeal requests and associated information are reviewed by clinicians not previously involved with the case.Must be submitted through the Provider Portal (the most efficient method) or the Claim Dispute Form. ![]()
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