Medical Necessity Appeals

Standard Medical Appeals

Medical necessity appeals must be submitted within 30 days after the member or provider receives a letter from CareSource denying coverage. CareSource may request additional information from the provider to document medical necessity.

Providers may use the Provider Grievance/Appeal Form in Provider Materials, but they are not required to. Medical necessity appeals should include:

• The member’s name, Hoosier Health ID number, and date of birth.
• The provider’s name and CareSource provider billing number.
• The type of service for which CareSource denied coverage, and the date and place when it was to be provided.
• The reason CareSource’s decision to deny coverage should be reconsidered.
• 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 standard medical appeals within 15 days.

CareSource will not penalize any member or provider in any way for appealing a medical necessity decision.

For more information, please call the CareSource provider service center Monday through Friday between 10 a.m. and 2 p.m. at 1-866-930-0017 or see the Provider Manual.

Expedited Medical Appeals

A provider may ask CareSource to expedite a medical necessity appeal if:

• The member is to be admitted to an inpatient facility.
• The member is within a continuing stay at an inpatient facility.
• The member has received emergency services but has not been discharged.
• 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 provider service center at 1-866-930-0017 and following the prompts (2 to speak to someone about prior authorization, then 4 for medical appeals).

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 standard process for medical necessity appeals, which is to resolve the appeal within 15 days.

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.

For more information, please call the CareSource provider service center at 1-866-930-0017 or see the Provider Manual.