Claims Disputes
Our contract with the Indiana Office of Medicaid Policy and Planning expired as of December 31, 2006.
CareSource will continue to pay provider claims throughout the run out period. Our claims submission timelines remain the same at 180 days for participating providers and 365 days for non-participating providers. In addition, CareSource's standard appeals process will remain in place throughout the claims run-out period. Our current provider manual and other provider forms can be found on this website and will be accessible through the end of 2007.
For assistance with claims issues, please contact:
Provider Services
Hours: 10 a.m. to 2 p.m., Monday – Friday
Phone: 1-866-930-0017
Fax: 1-877-725-4547
Please keep in mind that CareSource is committed to paying claims within prompt pay requirements, and will do so unless additional information is needed to process the claim or the claim involves medical necessity review or coordination of benefits. Our Coordination of Benefits (COB) unit can be reached by fax at (937) 396-3139 or by e-mail at cobindiana@csmg-online.com. During the transition period, we will not respond to claims status request for claims less than 45 days old.
We thank you for your partnership with CareSource and wish you the best as you move forward in supporting the Hoosier Healthwise program.
Informal Claims Disputes
A provider may initiate the informal claims dispute procedure if:
- The provider objects to CareSource’s decision regarding payment of a claim, including the amount paid.
- The provider objects to CareSource’s determination that a claim lacks sufficient supporting information.
- CareSource fails to notify the provider within 30 days of submitting a claim that we will either pay or deny the claim or that we need more information to process the claim.
Providers have 60 days from receipt of a claim determination or submission of the claim without receiving a claim determination to file an informal claims dispute. Written notice of the dispute must include an explanation of what the provider is objecting to and why.
Providers may send the notice to:
CareSource
One S. Main St.
Dayton OH 45402
Attn: Claims Department – Informal Dispute
CareSource will acknowledge receipt of an informal claims dispute within five business days of receiving it. The Claims Department will resolve the issue within 30 days of receiving it.
If the dispute is approved, the claim will be adjusted for payment. If additional documentation is required, the provider has 30 days after receiving the request for the documentation to submit it.
If the provider does not submit the additional documentation within 30 days, the dispute will be denied. If the dispute is denied, CareSource will issue a written notice of denial to the provider.
Regardless of whether the dispute is approved or denied, CareSource will notify the provider within five business days of reaching a decision.
For more information, please call see the Provider Manual.
Formal Claims Disputes
If the claims dispute is not resolved to the provider’s satisfaction within 30 days of submitting it for informal resolution, or within 30 days of submitting additional documentation, the provider then has up to 60 days to file a formal claims dispute.
To file a formal claims dispute, a provider simply has to give written notice to CareSource.
Providers may send the notice to:
CareSource
One S. Main St.
Dayton OH 45402
Attn: Claims Department – Formal Dispute
CareSource will acknowledge receipt of a formal claims dispute within five business days. A panel selected by CareSource will conduct the formal claims dispute resolution. The panel will not include anyone involved in any previous consideration of the dispute.
The panel will consider all information and material submitted by the provider that bears directly on the issue in the dispute. The provider may appear in person, or communicate with the panel through other means if unable to appear, and question the panel about the issues involved.
The panel will notify the provider in writing of its determination within 45 days of the time the formal claims dispute was received. The notice will include, as applicable, a detailed explanation of the factual, legal, policy and clinical basis of the determination.
Binding Arbitration
If the provider is unhappy with the outcome of the formal dispute process, he or she may submit the dispute to binding arbitration. The provider has up to 60 days after receiving the panel’s determination to submit the claim to binding arbitration.
Binding arbitration will be conducted in accordance with the rules and regulations of the American Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as adopted by Indiana at IC 34-57-2, unless the CareSource and the provider mutually agree to some other procedure.
The fees and expenses of the arbitration will be paid by the non-prevailing party.
For more information, please call the CareSource provider service center at 1-866-930-0017 or see the Provider Manual.