CareSource plans may require a referral or prior authorization for some services, while appeals offer a way to challenge certain coverage decisions. The requirements depend on the plan and service, so check your plan documents or contact CareSource before arranging care.
Understanding referrals, prior authorization and appeals can help you know what steps to take—and what to do if a request is denied. For a broader look at how another insurer’s coverage, care networks and member services fit together, see our overview, “UnitedHealthcare: How Coverage, Care Networks and Member Services Fit Together.”
| Situation | What the supplied material says | What to verify |
|---|---|---|
| Ohio Medicaid specialist care | Referral required for most participating specialists | Referral for the specific specialist and service |
| Georgia Marketplace in-network specialist | No referral or PA required before seeing an in-network specialty physician in the cited manual | Whether the provider requires a referral to schedule |
| Out-of-network service | PA needed before CareSource will pay, with stated emergency and in-network-facility exceptions | Plan-specific PA requirement and exception |
| Service requiring PA | Provider manual says authorization should come before service delivery | Who submits the request and whether approval is recorded |
- 1-800-390-7102 Medical Management Department phone number provided for prior-authorization requests
- 2 distinct plan-market examples in the supplied materials: Ohio Medicaid and Georgia Marketplace
What is the difference between a referral and prior authorization?
Referral: permission to seek care
A referral directs or approves a member’s care, often from a primary care provider (PCP) to a specialist or service; prior authorization is a separate request for CareSource’s approval before a service is delivered when the plan requires it. CareSource’s rules vary by plan and service, so a referral should not be treated as proof that prior authorization is also in place.
- Referral: CareSource’s materials say a referral is required for members to be evaluated or treated by most participating specialists. Some providers may also require one before scheduling a new patient.
- Prior authorization: CareSource must approve services that the member’s plan lists as requiring PA before those services are delivered. The referral and PA address different requirements; check whether both apply.
Prior authorization: approval before service
CareSource members can call the Medical Management Department at 1-800-390-7102 to request prior authorization. CareSource’s materials also distinguish referral rules from PA rules: for example, the plan may require a referral for specialist care, while PA may be required for a particular service. Confirm the requirements for the specific plan and service before care begins.
Do CareSource members need referrals for specialists?
CareSource members may need a referral for a specialist, depending on the plan: the Ohio Medicaid provider FAQ says a referral is required for evaluation or treatment by most participating specialists, while the Georgia Marketplace Provider Manual says referrals are not required for visits to in-network specialty physicians.
Ohio Medicaid and Georgia Marketplace rules differ
- Ohio Medicaid: The CareSource provider FAQ requires a referral for members to be evaluated or treated by most participating specialists.
- Georgia Marketplace: The CareSource Provider Manual says members do not need a referral or prior authorization before seeing in-network specialty physicians. It also notes that some providers require a referral before scheduling new patients.
These rules come from different CareSource materials for different markets, so neither should be treated as a universal rule for every plan. Before booking, check the current requirements for your exact CareSource plan and confirm whether the specialist requires a referral to schedule you.
When does CareSource require prior authorization?
CareSource requires prior authorization before it will pay for services from an out-of-network provider, except for emergency care or when an out-of-network provider treats a member at an in-network facility.
Out-of-network care
For out-of-network services, the key distinction is whether either stated exception applies. A referral and prior authorization are not interchangeable: the supplied summary says members do not need prior authorization to see in-network specialty physicians, while a referral is required for evaluation or treatment by most participating specialists.
- Out-of-network provider: obtain prior authorization before the service if CareSource is expected to pay.
- Emergency care: this is an exception to the stated out-of-network authorization requirement.
- In-network facility: an out-of-network provider treating a member there is also an exception.
Timing matters
CareSource’s provider manual says services requiring prior authorization must be authorized before delivery; it warns that claims may not be paid when required authorization was not obtained. Contact the Medical Management Department at 1-800-390-7102 to request prior authorization, and do so before the service rather than waiting until after care has been provided.
How can you check approval rules before an appointment?
Check the rules for your specific CareSource plan before the appointment by reviewing its referral and prior-authorization materials, then confirm the requirements with your providers. CareSource has separate documents for Medicaid and Georgia Marketplace plans, so don’t assume one plan’s rules apply to another.
Confirm the referral and authorization steps
- Ask your PCP about the exact service. Give the PCP the specialist’s name or describe the lab test, X-ray or physical therapy service. CareSource’s member information lists those services as examples that may require a referral.
- Ask the ordering provider about prior authorization (PA). Confirm whether the service needs PA and who will submit the request. CareSource’s provider materials say that services requiring PA should be authorized before they are delivered.
- Call CareSource Medical Management if you still have PA questions. Use 1-800-390-7102 and ask what information is needed before the service date.
CareSource’s rules can differ by plan and service: its materials say some care may need a PCP referral, while PA requirements are a separate check. Getting both answers for the named service helps clarify what must happen before the appointment.
What should you do if CareSource denies a service or claim?
If CareSource denies a service or claim, gather the denial notice and supporting records, then use the Appeals page on the CareSource website to appeal an unsatisfactory medical-necessity decision or claim-payment action. The supplied information describes this route for health partners; it does not establish that every member has identical appeal rights.
Build a clear record
For a CareSource appeal, collect the denial notice, details of the affected claim or requested service, and records explaining why the care was needed. Ask the provider for clinical documentation and a clear explanation of the reason for the service; these materials can help address the decision being challenged.
- Medical-necessity decision: include the provider’s clinical records and explanation of the requested care.
- Claim-payment action: identify the relevant claim and keep its denial notice with the appeal materials.
Check the plan’s appeal instructions
CareSource’s Appeals page is the stated place for health partners to appeal, but the supplied information does not give an appeal deadline or another filing method. Check the denial notice and the applicable plan documents for the deadline, submission instructions, and member-specific rights before filing; do not assume the health-partner process applies to a member’s case.
When can these steps fail or need extra checking?
CareSource referral and prior-authorization rules can differ by plan and market, so a rule in one document may not apply to another. The Georgia Marketplace provider manual and the Ohio Medicaid FAQ describe different referral requirements: the Georgia manual says CareSource does not require a referral before an in-network specialist visit, while Ohio’s FAQ says most participating specialists require one for evaluation or treatment.
The Georgia Marketplace manual also cautions that an in-network specialist may still require a referral to schedule a new-patient appointment. Check with both the specialist’s office and CareSource before booking; network status alone does not settle the scheduling requirement.
Check referral and PA separately
A referral is not the same as prior authorization (PA). The CareSource provider manual says any required PA must be approved before the service is delivered; a referral does not replace that approval. Because the available materials do not establish current rules for every service, plan, or appeal deadline, confirm the requirement for the specific service with CareSource and the provider. For PA questions, the supplied summary lists CareSource’s Medical Management Department at 1-800-390-7102.
Where can you read more about CareSource and coverage?
For a broader explanation of coverage, care networks and member services, read “UnitedHealthcare: How Coverage, Care Networks and Member Services Fit Together.” That overview provides wider insurance context; it does not establish CareSource’s plan-specific approval rules.
For CareSource decisions, check the materials for your own plan before arranging a service. The rules can depend on the service and provider: CareSource’s Medicaid guidance, for example, says referrals are required for members to be evaluated or treated by most participating specialists, while other CareSource materials describe services that need a referral. A broader overview cannot resolve those plan-specific differences.
What to have ready when you ask
When asking CareSource or a provider to clarify next steps, keep the plan name, service, provider-network status and any denial notice together. These details help identify which approval rule or appeal process applies; the CareSource site’s Appeals page is the place for health partners to pursue an appeal about a medical-necessity decision or claim payment. For a prior-authorization request, the supplied CareSource information lists the Medical Management Department at 1-800-390-7102.
Frequently asked questions
Does CareSource require a referral to see a specialist?
What number can I call about prior authorization?
Can CareSource refuse payment if prior authorization was not obtained?
Where can a CareSource denial be appealed?
Key takeaways
- Referral rules differ between the supplied Ohio Medicaid FAQ and Georgia Marketplace manual.
- The PA contact number provided is 1-800-390-7102.
- Required prior authorization should be obtained before service delivery.
- CareSource’s Appeals page is identified for challenging certain medical-necessity or claim-payment actions.
Sources
- caresource.com — “[PDF] Provider Manual – CareSource”
- CareSource — “FAQs | Ohio – Medicaid”
- caresource.com — “110 CareSource Provider Manual Referrals and”
- CareSource — “Referrals & Prior Authorization”
- CareSource — “FAQs | Indiana – Medicaid”
