Provider Appeal Form for CareSource Claims
The CareSource Provider Appeal Form is used to request reconsideration of claim denials or medical necessity decisions. Ensure all required fields are completed and legible to avoid delays in processing. Submit this form as the first page of your appeal with all supporting documentation.
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How do I fill this out?
Start by ensuring you have all necessary information ready. Complete all required fields, making sure they are legible. Attach any supporting documentation and submit according to the provided instructions.
How to fill out the Provider Appeal Form for CareSource Claims?
1
Gather all necessary claim and member information.
2
Complete all required fields on the form legibly.
3
Attach all relevant supporting documentation.
4
Ensure the form is the first page of the submission.
5
Submit the form through the preferred method or mailing address.
Who needs the Provider Appeal Form for CareSource Claims?
1
Healthcare providers who need to appeal a claim denial.
2
Providers disputing a medical necessity decision.
3
Doctors needing reconsideration for multiple claims with similar issues.
4
Medical practitioners representing a member for a pre-service appeal.
5
Administrative staff responsible for handling claim appeals for their practice.
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Save your changes and download the completed form.
What are the instructions for submitting this form?
To submit the CareSource Provider Appeal Form, ensure all required fields are completed legibly. Attach all relevant supporting documents and make sure this form is the first page of your submission. You can submit the form online via the CareSource Provider Portal or mail it to CareSource, Attn: Provider Appeals, P.O. Box 2008, Dayton, OH 45401-2008. Alternatively, fax your submission to 937-531-2398. It's recommended to retain copies of all submitted documents for your records.
What are the important dates for this form in 2024 and 2025?
Ensure timely submission of appeal forms within the filing limits. Specific dates for 2024 and 2025 may vary based on individual claim circumstances. Always refer to the latest guidelines provided by CareSource.
What is the purpose of this form?
The purpose of the CareSource Provider Appeal Form is to facilitate the reconsideration of claim denials and medical necessity decisions by healthcare providers. This form ensures that appeals are submitted in a structured and organized manner, with all necessary information and supporting documentation included. By using this form, providers can streamline the appeal process and improve the chances of a favorable outcome.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Name: The name of the healthcare provider submitting the appeal.
- 2. NPI Number: The National Provider Identifier number of the healthcare provider.
- 3. Tax ID Number: The tax identification number of the healthcare provider.
- 4. Member Name: The name of the member for whom the appeal is being filed.
- 5. Member Date of Birth: The date of birth of the member.
- 6. CareSource Member ID #: The identification number assigned to the member by CareSource.
- 7. Original Claim (ICN) Number: The internal control number of the original claim.
- 8. Service From/To Dates: The dates of service for the claim being appealed.
- 9. Appeal Type: Indicate whether the appeal is for a claim denial or medical necessity decision.
- 10. Appeal Description/Reason: A description or reason for the appeal.
- 11. Contact Name: The name of the person to contact regarding the appeal.
- 12. Title: The title of the contact person.
- 13. Contact Phone Number: The phone number of the contact person.
- 14. Fax Number: The fax number to send the appeal response to.
- 15. Address for Appeal Decision Notices: The mailing address to send appeal decision notices to.
- 16. Signature: The signature of the person submitting the appeal.
- 17. Date: The date the appeal form is signed.
What happens if I fail to submit this form?
Failure to submit the form correctly may result in delays or denial of the appeal. It is crucial to follow the instructions provided and complete all required fields.
- Delay in Processing: Incorrect or incomplete submissions can cause significant delays in the appeal review process.
- Denial of Appeal: Incomplete forms or missing information may lead to the denial of the appeal.
How do I know when to use this form?
- 1. Claim Denial Appeal: When a claim has been denied and you seek review of that decision.
- 2. Medical Necessity Appeal: When disputing a decision regarding the medical necessity of a service.
- 3. Multiple Similar Claims: When appealing multiple claims with substantially similar issues.
- 4. Pre-Service Appeal: When filing a pre-service appeal on behalf of a member with written consent.
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Submit the form through the provided mailing address, fax number, or online portal as instructed.
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