CareSource billing: timely filing limit, appeals and denials

CareSource filing, prior authorization and portal

Appeal levels

Top denials from CareSource

What is the CareSource timely filing limit?

CareSource's filing limit changes with the product. The Georgia Medicaid provider manual (approved by the Georgia Department of Community Health on May 26, 2023) requires claims within 180 calendar days of the date of service or discharge. The 2024 Ohio Marketplace provider manual allows 365 calendar days from the date of service or discharge.

Georgia adds that providers have "180 calendar days from the date of service or discharge or 90 days from the EOP date to submit a clean claim." Interim bills on long stays are paid at 30 percent of billed charges, and the final bill is due within 180 calendar days of discharge or the claim denies and earlier payments are recouped. Newborn claims follow the same limit and must use the newborn's CareSource ID, not the mother's.

A claim that misses the window denies as CO-29; date counting is in timely filing limits by payer. Georgia's own rules are on our Georgia page.

How do I submit and check CareSource claims?

Send electronic claims through Availity or the CareSource Provider Portal, using the payer ID for the state and product.

Both manuals require the NPI and tax ID on every claim; Georgia says claims without them are rejected. The Ohio Marketplace portal updates claim status daily and searches 24 months of claims.

How do I send a corrected claim to CareSource?

Send a corrected claim, not an appeal, when a claim was processed wrong because of incomplete, incorrect or unclear information. Both manuals say corrected claims do not go through the appeal or dispute process, and Georgia limits them to 180 calendar days from the date of service or discharge.

1. Georgia 837P or 837I: put value 7 in CLM05 in the 2300 loop and add REF*F8 with the most recent claim number for the claim you are correcting.
2. Use the most recent claim number from the original claim ID. Georgia warns that the claim is rejected otherwise.
3. Ohio Marketplace: the portal offers an easy corrected-claim submission when the original went in online.

What are the CareSource appeal levels and deadlines?

Georgia Medicaid has a claim payment dispute for payment amounts, a claim appeal for denials, and a hearing or arbitration after that. The deadlines are short: a claim appeal is due within 30 calendar days of the date the adverse action, denial of payment, remittance advice or initial review determination was mailed.

Two more points from the manual. Appeals on several claims with the same or similar coverage issue can be bundled into one appeal, whatever the number of members or claims. And an appeal that misses the 30 days is not considered, and you are notified of the dismissal in writing.

Georgia's arbitrator must be certified by a nationally recognized association, with a ruling within 90 calendar days of selection and costs other than attorney's fees shared equally. The Ohio Marketplace manual contradicts itself on the first-level window: its Claim Processing Guidelines list says 60 days after receipt of the written determination, and its Claim Dispute Process section says 90 calendar days. Use the shorter figure unless your contract says otherwise. Georgia peer-to-peer requests are due within five business days of the denial letter, one per denied service, and not available for timely filing or administrative denials.

Does CareSource require prior authorization?

Some services do, and each manual points to a lookup tool. Georgia directs providers to the Prior Authorization List and the Procedure Code Lookup Tool on CareSource.com, and the Ohio Marketplace manual uses the Procedure Code Look-Up Tool. Georgia Medicaid decides standard requests no later than three business days after receipt.

For emergencies, Georgia says CareSource will not deny or reduce payment for emergency care or make payment contingent on notification. Emergent inpatient admissions should be reported within 24 hours of admission. Participating providers need no authorization for post-stabilization services in the emergency department or observation, while non-participating providers need one through GAMMIS. Missing authorizations are the pattern behind CO-197.

What are the common causes of CareSource claim denials?

These come from the claims sections of the two manuals rather than a published reason-code table.

• Timely filing: 180 days in Georgia Medicaid or 365 in Ohio Marketplace, including a late final bill after interim billing.
• Coordination of benefits: a COB denial is cured by sending the primary payer's EOB inside the allowed period.
• Newborn billed under the mother's ID: Georgia denies it, and birth weight is required on newborn claims.
• Missing NPI or tax ID: Georgia rejects claims that omit them.
• Wrong channel: a correction sent through an appeal or dispute instead of as a corrected claim.

How does CareSource handle out-of-network claims under the No Surprises Act?

The Ohio Marketplace manual says CareSource presumes emergency services, including post-stabilization, and out-of-network services at in-network facilities are covered under the No Surprises Act. It applies from dates of service starting January 1, 2022. Claims paid under the Act carry remark code N830 on the electronic remittance advice or Explanation of Payment.

• Outpatient facility emergency claims: bill revenue codes 0450 to 0459, or 0762.
• Inpatient post-stabilization claims: use admit type 1, 2 or 5.
• Professional emergency claims: place of service 23.
• Notice and consent: providers need not send notice and consent documentation with claims, though prior authorization still applies where medical necessity review is required.

To start open negotiation, the manual says to email an Open Negotiation Notice to CareSource's Grievance and Appeals department at MarketplaceIDR@CareSource.com within 30 business days of the initial payment or notice of denial. If the 30-day negotiation fails, the manual says federal IDR may start within four days after it ends; the federal rule counts four business days, explained on our IDR process and open negotiation pages. This is a Marketplace process; the Georgia Medicaid manual has none.

Where does CareSource operate and how do the rules differ?

CareSource appears on our state pages for Georgia, Ohio, Indiana and Wisconsin. Those pages name the plan; the manuals above give the figures for Georgia Medicaid and Ohio Marketplace. For Medicaid plans in other states, read that state's CareSource manual before you rely on these numbers.

Compare Molina Healthcare, Ambetter or the national Medicaid guide, or go back to all payer guides.