CareSource Insurance Denial Appeal Guide

CareSource Appeal Process

CareSource processes vary by plan type (Medicaid vs marketplace) and state.

Medicaid Managed Care Appeals

1. Internal grievance/appeal — file within 30-90 days depending on state
2. State fair hearing — right to a hearing before your state's Medicaid agency
3. Aid continuing — request within 10 days to continue services during appeal

Marketplace Plan Appeals

1. Internal appeal — within 180 days of denial
2. External review — after internal appeal exhaustion
3. State insurance department — for regulatory complaints

Common Denial Reasons

• Service not covered under Medicaid benefits
• Prior authorization not obtained
• Non-participating provider used
• Medical necessity not met
• Benefit limits reached

Tips for CareSource Appeals

• CareSource has care coordinators who can help navigate the system
• For Medicaid, always request aid continuing within 10 days
• Each state has its own Medicaid advocacy organizations that can assist for free
• Document all calls with CareSource including representative names and reference numbers