CurrentCareSourcePolicy N/A
Certificate of Coverage (CareSource) — Terms, Conditions, Exclusions, and Limitations of Coverage
Customize your policy alerts
Sign up for all CareSource policy alerts
Know when CareSource releases new policies or updates existing guidance.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Governs the terms, conditions, exclusions, and limitations of CareSource health insurance coverage for covered persons, including in‑network requirements, prior authorization rules, and member rights and responsibilities.
Policy Summary
PayerCareSource
PolicyCertificate of Coverage (CareSource)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain Prior Authorization on behalf of members before delivering Covered Health Services that require it.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
EPOPlan type (Exclusive Provider Organization — in-network only)
RequiredPrior authorization
No OONOut-of-network restriction
ExcludedPediatric dental
877-514-2442Member Services
Up to 4yAutism intensive duration
Coverage rules, limits, and exclusions
Network and Authorization Coverage Rules
Coverage is limited to Covered Health Services provided by In‑Network Providers; out‑of‑network benefits are available only in narrowly defined circumstances.
Covered Health Services must be provided by In‑Network Providers (EPO plan).
EPO: in‑network requirement applies to benefits and payment.
Limited Out‑of‑Network Exceptions
- Emergency Health Services provided by Out‑of‑Network Providers (covered at In‑Network level subject to Qualifying Payment Amount).
- Medically necessary urgent care when traveling out of the Service Area or dependent students receiving specified behavioral services outside the Service Area (follow‑up by In‑Network Providers required).
- Out‑of‑Network services with a written Out‑of‑Network Authorization initiated by an In‑Network Provider and approved by CareSource prior to services being rendered.
Out‑of‑Network payment is limited to the Maximum Allowed Amount; members may be balance billed for amounts above the Maximum Allowed Amount except where law restricts balance billing.
Balance billing and MAA rules apply per definitions.
Certain services require Prior Authorization; failure to obtain required Prior Authorization may reduce or exclude benefits and may subject the member to a penalty per Section 6; Prior Authorization is a medical necessity determination, not a guarantee of payment.
Members may contact Member Services (877‑514‑2442) or use the Find a Doctor tool to confirm provider network status and estimate out‑of‑pocket expenses.
Coverage criteria and limits (partial)
Coverage is provided for Medically Necessary services rendered by In‑Network Providers and is subject to the Policy's definitions, financial limits, and utilization controls.
Services must meet the Policy definition of Medically Necessary (consistent with accepted standards, clinically appropriate, not experimental, appropriate site/level and least costly effective alternative).
Coverage is available only from In‑Network Providers except for limited circumstances (see Network rules); In‑Network cost‑sharing (Deductible, Copayment, Coinsurance) and Schedule of Benefits apply.
Financial limits (Deductible, Copayments, Coinsurance, Out‑of‑Pocket Maximum) apply; amounts in excess of the Maximum Allowed Amount and certain financial assistance do not count toward the Out‑of‑Pocket Maximum.
Prior Authorization, Quantity Limits, Step Therapy, and Age Limits may apply per the Formulary and utilization management controls; Out‑of‑Network Authorizations must be initiated by an In‑Network Provider and will be denied if In‑Network alternatives reasonably exist.
Experimental, Investigational or Unproven services are excluded unless otherwise specified and routine patient care costs for qualifying clinical trials may be covered as described in Section 7 and Section 123.
Coverage criteria and administrative rules (partial)
Administrative rules and programmatic requirements that affect coverage determinations.
CareSource may consult expert opinion and apply clinical policies and criteria when determining Medical Necessity; determinations are for payment purposes and not clinical directives.
Providers must submit Prior Authorization requests with appropriate documentation; non‑emergency prior authorization requests must be received at least 15 business days prior to the service; urgent/emergency hospital admission notifications must be made within 48 hours or as soon as medically able.
CareSource may establish quantity limits, determine rental vs purchase for DME, and may delegate administrative authority; Providers must provide requested information within required timeframes or reimbursement may be impacted.
Premium payment and grace period rules affect coverage effective dates and potential termination (31‑day grace if no APTC; three‑month grace if receiving APTC).
Coverage criteria and termination events
Events that can lead to termination or suspension of coverage and the applicable member obligations.
Premium payment and grace periods
- If member does not receive APTC and fails to pay Premium within 31 days after due date, coverage terminates as of the last day of the last month for which premium was received.
- If member receives APTC and fails to pay Premium, a three‑month grace period applies; if premiums remain unpaid at end of grace, coverage terminates as of last day of first month of grace period.
Failure to pay premiums as required may result in termination and return of payments made for inactive periods less any claims paid for those periods.
Members must notify CareSource within 48 hours (or as soon as reasonably possible) if hospitalized when coverage begins to ensure benefits payable from first day of coverage if services meet Policy terms.
To add a newborn, members must notify and pay required premium within 60 days to continue coverage; retroactive benefits may be possible if paid within applicable timeframes.
Other termination events
- Nonpayment of premium.
- Fraud or intentional misrepresentation.
- Loss of eligibility or moving out of Service Area (coverage ends 60 days after move).
Coverage criteria and exceptions
How to obtain Covered Health Services and key exceptions to the in‑network requirement.
Benefits are provided when Covered Health Services are obtained from In‑Network Providers; services from Out‑of‑Network Providers are not covered except in limited situations described in the Policy.
Emergency Health Services provided by Out‑of‑Network Providers are covered at the In‑Network level; follow‑up care must be by In‑Network Providers.
Out‑of‑Network services may be covered only if a written Out‑of‑Network Authorization is obtained from an In‑Network Provider and approved by CareSource before services are rendered; failure to obtain approved authorization results in no payment and possible penalties.
Members may be balance billed by Out‑of‑Network Providers for amounts above the Maximum Allowed Amount for certain limited services; members are not balance billed for emergency services or covered ancillary services at In‑Network facilities.
Continuity of Care: if a Provider who was in‑network at enrollment leaves the network, members may continue access to that Provider at In‑Network benefits for specified timeframes (PCP through policy year; non‑PCP up to 90 days or end of treatment/policy year), with special provisions for pregnancy; contact Member Services to exercise rights.
Providers are required to obtain Prior Authorization on behalf of members before listed Covered Health Services are provided; non‑emergency prior authorization requests must be submitted at least 15 business days prior to the service; failure by a Provider to obtain prior authorization may result in member penalty (50% up to $1,500 per service).
Coverage rules and criteria
Coverage stance, specified criteria, common limits, and notable exclusions across multiple service areas.
Behavioral Health & SUD: In‑network licensed providers and telehealth services cover inpatient, partial hospitalization, day treatment, intensive outpatient, residential, evaluations, treatment planning, medication management, individual/family/group therapy, and crisis intervention when medically necessary.
Autism Services: Intensive and non‑intensive evidence‑based autism therapies are covered when delivered by qualified providers per treatment‑plan requirements; intensive level requires >=20 hours/week over six continuous months and intensive services are limited to up to four cumulative years; progress must be documented.
Limitations/Exclusions (Behavioral & Autism): Services lacking credible evidence, school‑based tuition/services, residential/inpatient treatments, listed therapies (e.g., acupuncture, animal therapy, auditory integration, chelation), travel time, childcare fees, and custodial care are excluded or limited.
Biofeedback & Botox: Biofeedback is covered for migraine, spastic torticollis, and urinary incontinence but not for TMD; botulinum toxin is covered for medically necessary non‑cosmetic indications (e.g., spasticity), but excluded for hyperhidrosis.
Cochlear Implant: Cochlear implants covered per FDA indications for severe‑to‑profound hearing loss; post‑implant aural therapy limited to 30 visits/year; accessories (batteries, cords) limited or excluded.
Clinical Trials: Routine patient care costs in qualifying in‑network clinical trials are covered if eligibility and trial criteria met; investigational items and trial costs remain excluded.
Section 7 coverage and exclusions
Section 7: enumerates covered services, limits, and exclusions for major clinical categories.
Behavioral Health & SUD Coverage: Covered inpatient, partial hospitalization, day treatment, intensive outpatient, residential treatment, evaluations, treatment planning, medication management, and crisis intervention when provided by licensed in‑network professionals or via telehealth.
Autism Services — Coverage & Limits: Evidence‑based intensive autism therapy covered when meeting intensive‑level criteria (treatment plan, qualified providers, >=20 hours/week over six months); intensive services limited to up to four cumulative years; progress and treatment plans may be requested periodically.
Exclusions — Behavioral & Autism: Non‑evidence‑based or unproven autism/behavioral therapies and listed items (acupuncture, animal therapy, hyperbaric oxygen, special diets, custodial care) are excluded; school‑based services duplicative of school services excluded.
Biofeedback and Botulinum Toxin: Biofeedback covered for specified indications (migraine, spastic torticollis, urinary incontinence); biofeedback for TMD excluded. Botulinum toxin covered for medically necessary non‑cosmetic indications; Botox for hyperhidrosis excluded.
Cochlear Implant Provisions: Cochlear implants covered per FDA label for severe‑to‑profound loss with limited benefit from hearing aids; post‑implant outpatient aural therapy limited to 30 visits/year; certain accessories excluded.
Observation and Emergency Rules: Observation stays covered up to 48 hours; stays beyond 48 hours require Prior Authorization; emergency services covered whether in‑network or out‑of‑network at network rate subject to Qualifying Payment Amount limits.
Segment coverage criteria
Summary of coverage criteria and limits for selected benefit categories in this segment.
Cochlear Implant: Covered for individuals with severe‑to‑profound hearing loss per FDA indications; limited post‑implant therapy (30 visits/year).
Dental (Medical‑Necessity/Accident Only): General dental coverage limited to oral exams, x‑rays, extractions and non‑surgical services when directly required to treat a Covered medical condition; accident‑only dental services covered when criteria/timelines met (initial contact within 72 hours, treatment started within 3 months, completed within 12 months).
Diabetes Supplies & DME: Insulin, prescription diabetes supplies, certain non‑invasive CGMs and insulin infusion devices covered when on the Prescription Drug List; DME covered when prescribed by In‑Network provider and obtained from In‑Network DME provider; CareSource may set quantity limits and decide rental vs purchase.
Emergency & Observation: Emergency Health Services covered whether rendered in‑ or out‑of‑network; observation stays covered up to 48 hours, beyond which Prior Authorization required.
Genetic Testing: Genetic testing and counseling covered when Medically Necessary for diagnostic purposes.
Habilitative Services: Evidence‑based PT/OT/ST provided under written treatment plan are covered (20 PT/20 OT/20 ST visits per year) and are distinct from rehabilitative service limits.
Hearing services
Coverage and limits for hearing devices and related services.
Hearing aids are covered for Covered Persons certified as deaf or hearing impaired by a Provider or licensed audiologist; benefits include diagnosis, surgery, and therapy provided in connection with the hearing aid.
Bone‑anchored hearing aids covered only for craniofacial anomalies or absent ear canals that preclude wearable aids or when wearable aids are inadequate; limited to one bone‑anchored device per lifetime and repairs/replacement covered only for malfunctions or when Medical Necessity met; batteries and accessories excluded.
Hearing aids limited to one hearing aid per ear every 36 months.
Home Health
Home Health services require provider order and must meet skilled‑care criteria; visit limits apply.
Home Health services must be ordered by a Provider and provided by an in‑network state‑licensed or Medicare‑certified Home Health Agency; services must be part‑time or intermittent and require skilled care.
Skilled care must be delivered or supervised by licensed technical or professional medical personnel and is distinct from custodial care.
Home health benefits are limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one visit; home health aide visits are excluded.
Hospice
Hospice care covered when terminal prognosis and documentation requirements are met.
To be eligible for hospice Benefits, the patient must have a life expectancy of one year or less as confirmed by the attending Provider; hospice care must be provided by a licensed hospice agency and be part of an approved treatment plan.
Provider and hospice medical director must certify terminal status and the hospice must maintain a written treatment plan; Provider must consent to hospice care and be consulted on the treatment plan.
Covered hospice services include interdisciplinary team care, skilled nursing, home health aide under RN supervision, short‑term inpatient facility care for crisis or respite, social services, PT/OT/ST, dietary support, pharmaceuticals and equipment for palliation.
Palliative Care
Palliative care is supportive symptom management and requires provider order and in‑network hospice certification.
Palliative Care is covered when ordered by a Provider and provided by an in‑network hospice‑certified Provider; interdisciplinary team provides symptom management and support to remain at home.
Inpatient and Rehabilitation
Inpatient services and inpatient rehabilitation are covered when medically necessary and subject to participation and day limits.
Inpatient coverage includes room and board, ancillary services, operating/delivery rooms, prescription drugs, diagnostic and therapy services; inpatient rehabilitation covered when patient can participate a minimum of three hours/day for five days/week and requires provider visits three times/week.
Inpatient skilled rehabilitation considered custodial or long‑term care is not covered; inpatient rehabilitation coverage is limited to 60 days per calendar year.
Kidney Treatment and Transplant
Kidney disease treatments including dialysis and transplant are covered with coordination rules; experimental transplants excluded.
Coverage includes inpatient and outpatient kidney disease treatment including dialysis, transplantation, and donor‑related services when recipient is a Covered Person; donor costs directly related to organ removal are payable through recipient's coverage.
Experimental or investigational transplants, transplants involving non‑human or artificial organs, and transplants not listed as covered are excluded; coordination with Medicare applies when member becomes Medicare eligible.
Maternity and Newborn
Maternity and newborn coverage includes standard inpatient stays and specific exclusions and limits.
Maternity coverage includes prenatal, postnatal, delivery and related complications; newborn coverage includes 96 hours for C‑section and 48 hours for vaginal delivery inpatient stay and routine exams prior to hospital release.
Elective abortions are excluded except to save the life/health of the mother or in rape/incest; home or out‑of‑hospital deliveries, birthing classes and donor milk are excluded; certain genetic tests for non‑medical reasons excluded.
Breast pumps covered if ordered by a licensed professional after birth; limited to one standard manual or one basic single electric pump.
Nutritional Services
Nutrition services are covered for disease‑specific education; many nutrition products and counseling remain excluded.
Nutritional education is covered when required for a disease or condition where patient self‑management is necessary and a knowledge deficit exists and is provided by licensed/registered professionals.
Individual/group nutritional counseling, infant formula, donor breast milk, over‑the‑counter formulas and supplements, and weight‑loss nutritional counseling are excluded except as specifically covered (e.g., diabetes services).
Oral Surgery
Oral surgery coverage is limited to specified medical indications; tooth‑related procedures are excluded.
Oral surgery is covered for excision of tumors, cysts and abscesses of jaws/cheeks/tongue/roof and floor of mouth and repair of traumatic maxillofacial injuries or fractures.
Oral surgeries for routine tooth extraction (e.g., wisdom teeth) and excision/treatment related to tooth abscesses are not covered.
Oral surgery coverage and exclusions
Oral surgery — covered indications and explicit exclusions.
Coverage: excision of tumors, cysts and abscesses of the jaws/cheeks/tongue/roof and floor of mouth; repair of traumatic maxillofacial injuries or fractures.
Exclusion: oral surgeries for tooth extraction (including wisdom teeth) and excision/treatment related to tooth abscesses are excluded from coverage.
Ostomy supplies coverage and exclusions
Ostomy supplies coverage limited to core supplies; ancillary items excluded.
Covered ostomy supplies include pouches, face plates, belts, irrigation sleeves, bags, ostomy catheters and skin barriers; CareSource may establish reasonable quantity limits.
Excluded items include deodorants, filters, lubricants, tape, appliance cleaners, adhesives and adhesive removers and other items not listed as covered.
Oral enteral/parenteral nutrition requirements
Enteral and parenteral nutrition are covered only when strict medical criteria are met.
Oral enteral and parenteral nutrition (medical foods) are covered when the product is a labeled medical food used as the primary source of nutrition (>50% of intake), labeled for dietary management of a specific disorder requiring distinctive nutritional requirements, and used under supervision/order of a Provider or registered dietician by referral.
When medically appropriate, enteral/parenteral feeding should be weaned to oral nutrition as soon as feasible; CareSource may establish reasonable quantity limits for related supplies/equipment.
Pharmaceuticals administered in outpatient settings
Certain pharmaceutical products administered in outpatient settings are covered; contact CareSource for details.
Coverage available for pharmaceutical products that must be administered or directly supervised by a qualified Provider in outpatient settings (hospital, alternate facility, provider office, or home); these are distinct from drugs dispensed through the Prescription Drug Benefit at a Network Pharmacy — contact CareSource for coverage details.
Podiatry coverage and routine foot care exceptions
Podiatry coverage focuses on medically necessary treatment; routine foot care generally excluded except in specified conditions.
Coverage includes treatment of foot disorders related to disease, injury or defects and medically necessary routine foot care for Covered Persons with certain chronic conditions (e.g., diabetes, peripheral vascular disease).
Routine foot care (cutting/parning/shaving thickened skin, trimming nails, hygienic care, custom shoes, cosmetic procedures) is not covered except for members with systemic illnesses compromising neurovascular integrity.
Preventive care coverage tiers and rules
Preventive services are tiered between no cost‑share and cost‑share depending on federal guidelines and context.
Certain preventive services are covered at 100% with no cost share when provided in‑network and consistent with USPSTF/ACIP/HRSA guidelines and age/setting appropriateness.
Some preventive services performed as part of visits may be subject to cost sharing depending on whether they are diagnostic rather than screening or follow abnormal results (e.g., colonoscopy with polyp removal, abnormal Pap follow‑up).
Prosthetics coverage and replacement rules
Prosthetic devices are covered when medically necessary; payment limited to device meeting minimum functional specifications.
Coverage includes external prosthetic devices that replace a limb or body part, including breast prostheses and related items; repairs and replacements covered except for misuse/loss/theft; devices fully implanted may be excluded unless Medically Necessary and ordered by a Provider.
If multiple devices meet functional needs, CareSource will pay only for the device meeting minimum specifications and the member is responsible for any cost difference for upgraded devices.
Provider office services and rehabilitation limits
Office‑based diagnostic and short‑term rehabilitation services are covered with visit limits and utilization oversight.
Office‑based services include diagnosis and treatment in provider offices (labs, x‑rays, allergy injections); major imaging (CT, PET, MRI) and nuclear medicine are excluded from routine office benefits.
Short‑term outpatient rehabilitation limits apply: PT 20 visits/year, OT 20 visits/year, ST 20 visits/year; cardiac rehab 36 visits/year; cognitive rehab 20 visits/year (post‑TBI/stroke); post‑cochlear implant aural therapy 30 visits/year; pulmonary rehab 36 visits/year.
Benefits may be denied or shortened if the member is not progressing toward goals or goals have been met; maintenance or preventive manipulative treatment is not covered.
Sterilization procedures and infertility/abortion exclusions
Sterilization procedures are covered when medically necessary; infertility treatments and elective abortion are excluded except limited exceptions.
Covered sterilization procedures include tubal ligation, oviduct occlusion and vasectomy when meeting medical necessity; removal of both fallopian tubes covered when medically necessary.
Services connected to reversal of sterilization, diagnostic tests connected to infertility treatment, assisted reproductive technologies (IVF, GIFT, ZIFT, ICSI), sperm/embryo storage, infertility medications, and elective abortions (except to save life/health or in cases of rape/incest) are excluded.
Reproductive and infertility services
Reproductive and infertility services: diagnostic and some treatments may be excluded; treatment of underlying causes may be covered while ART is excluded.
Assisted reproductive technologies and related services (IVF, artificial insemination, embryo transfer, sperm/egg storage) and infertility medications are not covered; diagnostic tests for infertility treatment are excluded.
Elective abortions are excluded except to save the mother's life/health or in instances of rape or incest; home or out‑of‑hospital deliveries are excluded.
Diagnosis and treatment of medically necessary underlying causes of infertility may be covered, but assisted reproductive technologies remain excluded.
Skilled Nursing Facility
Skilled Nursing Facility (SNF) benefits are conditionally covered when skilled care is required and subject to stay and renewal rules.
SNF coverage includes room and board (semi‑private or private when semi‑private unavailable) and ancillary services when skilled care is required; up to and including 30 days per stay.
Benefits available only if confinement is a cost‑effective alternative to inpatient hospital and skilled care (not primarily custodial) is provided; SNF benefit renews after 60 consecutive days without inpatient hospital or SNF skilled care.
Skilled Nursing Facility care that is primarily custodial or long‑term care is not covered even if provided by licensed staff.
Surgery and reconstructive rules
Surgical and reconstructive services covered when medically necessary; cosmetic, unsafe, or unproven procedures excluded.
Outpatient surgery and related facility charges, supplies, equipment, and provider services are covered when Medically Necessary and within policy limits.
Breast reconstruction following mastectomy and related prostheses and treatment of complications are covered per WHCRA with additional special rules.
Surgery that is cosmetic, unsafe, ineffective, experimental, or primarily for appearance (including bariatric surgery and related procedures) is excluded.
Telehealth
Telehealth visits are covered when rendered by in‑network qualified providers; certain remote communications are excluded.
Telehealth services may be Covered when rendered by In‑Network qualified providers; excluded or limited services remain excluded when delivered via telehealth.
Telephone‑only, text, email, asynchronous EHR messaging, patient portal messages and remote patient monitoring are not Covered as Telehealth Visits; CareSource may deny coverage for telehealth visits that cannot reasonably be completed online (e.g., comprehensive physical exams).
TMD services
Temporomandibular disorder (TMD) services covered when clear diagnostic criteria met; many TMD‑related modalities excluded as unproven.
TMD diagnostic and surgical/non‑surgical treatment covered when there is radiographic evidence of significant joint abnormality, condition caused by congenital/developmental/acquired deformity/disease/injury, procedure/device reasonable and appropriate, and purpose is to control/eliminate infection, pain or dysfunction.
Unproven or unconventional TMD diagnostic services and therapies (EMG, jaw‑tracking, thermography, kinesiography, certain imaging, occlusal adjustments, orthodontics, restorative prosthodontics, TENS, nutritional counseling, home therapy) are excluded.
Transplant services
Transplant services are covered when prior authorized and performed at designated facilities; many transplant‑related items and experimental transplants are excluded.
Certain organ and tissue transplants covered when ordered by a Provider and performed at Designated Facilities/Designated Providers/Centers of Excellence; donor costs directly related to organ removal are covered if recipient is a Covered Person.
Transplant services require Prior Authorization by CareSource; services and supplies in connection with transplants are not covered unless Prior Authorized.
Experimental/investigational transplants, transplants involving artificial or animal organs, and donor costs beyond organ removal (e.g., hotel/transportation) are excluded.
Urgent care, supplies, and pediatric vision
Urgent care, certain supplies, and pediatric vision benefits are available with specified limits.
Medically necessary urgent care center services covered; in‑network urgent care required for in‑network benefits within Service Area; out‑of‑area urgent care paid at Maximum Allowed Amount.
Intermittent and indwelling urinary catheters covered when medically necessary for permanent incontinence or retention; quantity limits may apply.
Pediatric vision: one annual eye exam and one pair of eyeglasses per calendar year for children through end of month they turn 19; basic frames covered once every 12 months; contact lenses consume the eyewear benefit frequency.
Vision Services Coverage
Vision benefit details and notable exclusions.
Basic eyeglass frames are covered once every 12 months for eligible children; contact lenses covered but will consume the eyewear benefit frequency when provided.
Adult routine eye exams (age 19 and older) without eye disease or specific diagnosis are not covered; implantable lenses and refractive surgery (e.g., LASIK) are excluded except intraocular lenses with cataract surgery or lenses for keratoconus.
Prescription Drug Coverage
Prescription Drug Benefit rules, network requirements, formulary structure, and utilization controls.
Only drugs/devices that are Medically Necessary and on the Prescription Drug Formulary (or approved via drug exception) are covered; certain off‑label uses may be allowed if supported by medical literature.
Prescription Drug Benefit covers only prescriptions filled at Network Pharmacies; specialty drugs must be filled at network specialty pharmacies; mail‑order is available and specialty/mail order supplies are subject to quantity limits (generally 30‑day supply).
Formulary utilizes tiers (Tier 0–4) which determine member cost‑sharing; utilization management controls (PA, QL, ST, AL) apply and providers/members may request exceptions or bypasses per process described.
Non‑formulary drug exception process is available; if granted, the drug is treated as an Essential Health Benefit subject to applicable cost‑sharing; denials are appealable and external IRE review timelines apply (72 hours standard, 24 hours expedited for expedited requests).
Prescription Drug Coverage stance and exclusions
Prescription drug utilization, prior authorization for controlled substances, exclusions, and external review processes.
Members or authorized representatives may request an external review (IRE) of a denied non‑formulary drug exception; standard review decision within 72 hours, expedited within 24 hours.
Prior Authorization required for opioid analgesics prescribed for chronic pain and other controlled substances as indicated on the formulary; PA process and documentation requirements apply.
Excluded prescription items include non‑FDA approved drugs, drugs dispensed outside coverage eligibility dates, drugs payable by other government programs (e.g., Medicare), OTC products not designated on formulary unless prescribed, compounded drugs with non‑FDA ingredients, and drugs covered under the Medical Benefit or inpatient/skilled stays.
Certain condition‑specific drug exclusions apply (e.g., appetite suppressants, hyperhidrosis, cosmetic uses, products considered natural/homeopathic); refer to formulary for specifics and contact Member Services for questions.
Exclusions (non-covered services)
Services and items explicitly excluded from coverage (non‑exhaustive list).
Common exclusion categories
- Services provided in a foreign country (unless emergency) and travel/transportation expenses; immunizations solely for travel are excluded.
- Private duty nursing, custodial care, domiciliary/maintenance care, home health aides (except as part of hospice), respite care (except hospice‑related), and long‑term care are excluded.
- Bariatric surgery, weight loss/obesity programs and related complications are excluded.
- Alternative/complementary therapies and numerous specific unproven services (e.g., acupuncture, herbal medicine, homeopathy, neurofeedback, meditation, massage therapy) are excluded.
- Certain dental/jaw cosmetic procedures, elective cosmetic surgeries, hair restoration, and services primarily for appearance are excluded unless medically necessary.
- Long‑term storage of body fluids/tissue (>30 days) and experimental advanced therapies (e.g., CAR T‑cell and gene therapies) are excluded.
- Services where the member has no legal responsibility to pay or for which payment would not ordinarily be made (including waived cost‑sharing) are excluded from Benefits.
Coordination of Benefits and Medicare rules
Coordination of Benefits rules and interactions with Medicare and other plans.
When a Covered Person has coverage under more than one plan, CareSource coordinates benefits so total payments do not exceed the Allowable Expense; Primary Plan rules determine payment order following standard NAIC‑based rules.
Primary Plan determination follows standard rules (employee coverage, dependent/parent rules, active vs retired employee, COBRA/state continuation) and specific tie‑breakers; Covered Persons must notify CareSource of other coverage.
CareSource may reduce benefits when Medicare is primary so combined payments do not exceed Medicare Eligible Expense; members eligible for Medicare should enroll and maintain both Part A and Part B.
CareSource may recover overpayments and has right of recovery; members/providers must supply requested information or claims may be denied; CareSource may use and disclose necessary information for COB administration.
CareSource may change policy provisions per permitted amendment rules; amendments are effective 31 days after notice, and benefit‑reducing amendments effective 60 days after prior written notice.
Coordination, rights, and general legal provisions
Coordination when Medicare is primary, member responsibilities, and second‑opinion rights.
When a member is enrolled in Medicare and Medicare is primary, CareSource reduces its benefits so combined payments do not exceed Medicare Eligible Expense; Medicare benefits are determined as if Medicare Parts A and B paid even in certain non‑covered or opt‑out scenarios.
Members eligible for Medicare should enroll in and maintain Part A and Part B; failure to follow Medicare Advantage plan rules may reduce Benefits and increase member out‑of‑pocket costs.
One second opinion per injury or illness by an In‑Network Provider is covered; prior authorization required when specified and an Out‑of‑Network Authorization is required for out‑of‑network second opinions.
Code tables, quantity limits, and numeric thresholds
Covered service categories (TOC excerpts)mixed
| No codes listed |
(no label)mixed
| No codes listed |
Reimbursement determinationmixed
| No codes listed |
No explicit procedure or drug codes in this excerptmixed
Out-of-Pocket Maximum caveats
Exclusions from OOP creditAmounts in excess of the Maximum Allowed Amount and payments for non‑Covered services do not count toward the Out‑of‑Pocket Maximum.
Financial assistance not creditedCoupons, savings cards, grants, special programs or gift/cash cards are not credited to the Out‑of‑Pocket Maximum unless required by state or federal law.
OON payments exclusionWhen the Plan pays an Out‑of‑Network Provider for limited Covered Health Services, amounts paid in excess of the Maximum Allowed Amount do not count toward the Out‑of‑Pocket Maximum.
Premium increase notice threshold
Notice triggerIf Premiums are reduced or benefits are amended in a way that reduces member rights, CareSource provides prior written notice; a 60‑day notice applies for benefit‑reducing amendments.
Amount threshold (policy note)Premium increase threshold referenced in brief: increases greater than 25% trigger additional notice requirements (see related amendment timing).
Standard amendment timingNon‑benefit‑reducing amendments generally effective 31 days after notice; benefit‑reducing amendments effective 60 days after prior written notice.
Member financial responsibility for amounts over Maximum Allowed
Member responsibility for balanceMembers may be responsible for the difference between the Out‑of‑Network Provider's billed amount and the Maximum Allowed Amount (Balance Billing) for limited OON services.
Payables for limited OON casesWhen limited Out‑of‑Network benefits apply (e.g., emergency, out‑of‑area urgent care, approved OON authorization), payment is limited to the Maximum Allowed Amount and member may owe the excess.
OON authorization restrictionOut‑of‑Network Authorization must be initiated by an In‑Network Provider and will not be approved if In‑Network Providers can reasonably provide similar care.
Autism intensive therapy duration threshold
Intensive therapy definitionIntensive‑level autism services are evidence‑based behavioral therapies that include at least 20 hours per week averaged over a continuous six‑month period.
Treatment plan requirementTreatment plans must define specific cognitive, social, communicative, self‑care, or behavioral goals, require member engagement, and include provider observation at least once every two months.
Duration capIntensive level services are covered for up to four cumulative years; prior intensive services from any payer may be credited toward the four‑year limit.
Post‑cochlear implant aural therapy visit limit
Annual visit limitOutpatient post‑cochlear implant aural therapy is limited to 30 visits per year.
Accessory exclusionBatteries, cords and other accessories for cochlear implants are excluded or limited as specified.
Medical necessity and scopeCochlear implants are Medically Necessary when used per FDA label indications for severe‑to‑profound hearing loss and related services follow policy limits.
Quantity limits
Authority to set limitsCareSource may establish reasonable quantity limits for certain supplies, equipment or appliances (Quantity Limits).
DME and supply examplesQuantity limits may apply to Durable Medical Equipment and supplies such as insulin infusion devices, oxygen regulators, infusion pumps and related consumables.
Bypass processProviders can request a bypass of a Quantity Limit by submitting clinical information electronically or by fax for review and approval.
Hearing aid frequency
Hearing aid frequencyOne hearing aid per ear every 36 months is covered for eligible Covered Persons.
Bone‑anchored device limitsBone anchored hearing aids limited to one per Covered Person per lifetime and covered only for specific indications (craniofacial anomalies, absent ear canals, or severe loss not remedied by wearable aids).
Accessory exclusionBatteries, cords and other accessories for hearing devices are excluded or limited.
Home Health visit limit
Home health visit limitHome health benefits are limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one visit.
Provider and setting requirementHome Health services must be ordered by a Provider and provided by an in‑network, state‑licensed or Medicare‑certified Home Health Agency; skilled nature must be demonstrated.
Excluded visitsHome health aide visits are excluded from Home Health benefits.
Inpatient rehabilitation limit
Inpatient rehab annual limitCoverage for inpatient skilled rehabilitation is limited to 60 days per calendar year.
Medical necessity for rehabInpatient rehabilitation coverage requires that the patient be able to participate (e.g., approximately 3 hours/day for 5 days/week) and meet medical necessity criteria.
Custodial care exclusionCare considered primarily custodial or long‑term is not covered even if provided in rehabilitation settings.
Enteral nutrition primary source threshold
Primary source thresholdOral enteral nutrition products are covered when the product is the primary source of nutrition (more than 50% of total nutritional intake).
Product labeling and supervisionThe product must be labeled for dietary management of a specific medical disorder and used under Provider or registered dietician supervision.
Weaning preferenceWhen medically appropriate, introduction to oral nutrition is preferred and enteral/parenteral feeding should be weaned as soon as able.
SNF days per stay
SNF days per staySkilled Nursing Facility room and board is covered up to and including 30 days per stay.
Renewal ruleSNF Benefit renews after no inpatient hospital or SNF skilled care for 60 consecutive days; there is no limit to the number of benefit periods but additional days not available until 60‑day gap met.
Coverage conditionsSNF coverage requires that confinement be a cost‑effective alternative to inpatient hospital care and that services provided are skilled rather than custodial.
Quantity and supply limits
Standard supply dispensing limitQuantity Limits (QL) and specialty drugs are generally limited to a 30‑day supply; specialty drugs must be filled at a specialty pharmacy.
Mail‑order exceptionMail‑order pharmacy may allow larger supplies (exceptions to the 30‑day limit) as specified by the plan and Schedule of Benefits.
Utilization controlsPrior Authorization, Quantity Limits, Step Therapy and Age Limits may apply to formulary drugs; providers can request bypasses or exceptions for clinical reasons.
External review decision timeframe
External review standard timeframeIndependent external review (IRE) determinations for denied non‑formulary drug exceptions are provided within 72 hours for standard requests.
Expedited external reviewIf expedited, verbal notification of the IRE determination is provided within 24 hours of receipt of the request.
Who may requestMembers or their authorized representatives, including providers, may request an external review of denied drug exception requests.
Billing timeliness
Claim submission deadlineHealth services for which billing is not received by CareSource within one (1) year from the time proof is otherwise required are not covered; timely billing requirement applies.
Effect of late billingServices billed after one year may be excluded from coverage per the policy's exclusions section.
Provider responsibilityProviders must submit timely claims and requested documentation to avoid denial or impact on reimbursement and benefits.
Prior authorization, documentation, and billing responsibilities
Prior Authorization
Prior Authorization Requirement
Benefits may be reduced or excluded if Prior Authorization (PA) is not obtained for services that require it. PA determinations are based on Medical Necessity and review of the advanced written request and supporting documentation. PA is not a guarantee of payment; final payment is determined when claims/bills are submitted and must match the services authorized.
- Services requiring PA are listed on the Prior Authorization list available at CareSource.com/mp-WI-pa or by calling Member Services at 877-514-2442.
- Non-emergency/non-urgent PA requests must be received at least 15 business days prior to the anticipated date of service; urgent or emergency admission notification rules differ (hospital admission notification within 48 hours for urgent/emergency).
- If services rendered differ from those authorized, payment may be modified and only paid for services actually delivered.
Prior Authorization
Out-of-Network Authorization
Requests for services from Out-of-Network (OON) providers must be initiated by an In-Network provider using an Out-of-Network Authorization request. OON Authorizations will not be approved if In-Network providers can reasonably provide the same or substantially similar care. Benefits will not be payable if the OON Authorization process is not followed.
- An OON Authorization is a written request from an In-Network provider asking that services be provided by an OON provider.
- See Section 5: Limited Covered Health Services from Out-Of-Network Providers for additional restrictions and balance billing information.
Note
Prior Authorization and Out-of-Network Authorization — rules and expectations
Prior Authorization rules depend on whether the service is Medically Necessary, whether the provider is In-Network, and on plan benefit limits and member cost-sharing. CareSource may set quantity limits (QLs), step therapy, and other utilization management controls. Providers should verify PA and benefit status before rendering services.
- Prior Authorization may be required for certain drugs (including some controlled substances and opioid analgesics) and outpatient-administered pharmaceuticals.
- Quantity limits (QL), Step Therapy (ST), Age Limits (AL) and PA flags are shown on the Formulary; providers may request bypasses electronically or by fax.
- CareSource may delegate administrative functions (e.g., pharmacy benefits administrator) and establish clinical protocols based on nationally recognized evidence.
Documentation Required
Home Health Ordering and Eligibility
Home health services are Covered only when ordered by a Provider and delivered by an In-Network, state‑licensed or Medicare‑certified Home Health Agency on a part‑time or intermittent skilled care schedule. Home health must be ordered; services must meet criteria (e.g., skilled care required, hospitalization or SNF would otherwise be needed, and no available immediate family care without undue hardship).
- Provider must order home health services.
- Services must be delivered by an In‑Network licensed or Medicare‑certified Home Health Agency.
- Covered when skilled care is required and other listed criteria are met.
Prior Authorization
Outpatient Pharmaceutical Administration — contact required
For outpatient-administered pharmaceutical products (e.g., drugs given in a hospital, alternate facility, provider office, or home), contact CareSource for coverage determinations. Some pharmaceuticals require PA, have QLs, or are subject to step therapy; providers must submit required clinical information to support PA requests.
- Contact CareSource at 877-514-2442 or use the Provider Formulary/Search Tool to verify coverage and PA requirements.
- PA for outpatient-administered drugs must include clinical justification and may be subject to quantity limits or step therapy.
- If a drug requires PA, the provider must submit medical history, prior drugs tried, and relevant tests — electronically or by fax using forms on the website.
Prior Authorization
Transplant Prior Authorization and Designated Facilities
Certain transplant services require Prior Authorization and must be performed at Designated Facilities using Designated Providers or Centers of Excellence. Donor costs directly related to organ removal are Covered only if the transplant recipient is Covered under this plan.
- Transplant services require PA; contact CareSource at 877-514-2442 for transplant guidelines and authorization procedures.
- Transplant services must be received at Designated Facilities/Designated Providers or Centers of Excellence for coverage.
- Donor evaluation, hospitalization, surgical and postoperative costs may be Covered when linked to a Covered recipient and PA is obtained.
Prior Authorization
Prior Authorization and Limit Bypass Process
When requesting Prior Authorization or requests to bypass formulary limits (QL, ST, AL), providers must submit pertinent medical history, prior therapies, diagnostic test results, and any other documentation requested. Requests can be submitted electronically via the Provider tools on the website or by fax using the forms available online.
- For PA and limit-bypass requests, include prior drug history, relevant tests, and rationale for medical necessity.
- Electronic submission is preferred; fax is an available alternative. Forms and instructions are on the CareSource Provider website.
- An approved request is not a guarantee of payment—coverage and member eligibility at time of service are required for benefits to be payable.
Documentation Required
Provider Information and Documentation Requirements
Providers must supply requested information, records, or documentation within 30 days when CareSource requests it for reimbursement or coverage determinations. Failure to provide accurate and complete information may result in denial of benefits or non-payment.
- CareSource may suspend or deny reimbursement if required information is not provided in a timely manner (within 30 days).
- Providers should cooperate with delegated service vendors and administrative processes to support benefit determinations.
- Member eligibility and policy effective date must be confirmed at time of service; coverage cannot be determined if documentation is incomplete.
Key definitions and term clarifications
Certificate
Document nameCertificate of Coverage (part of the Policy) — legal contract between CareSource and Covered Person describing Benefits, Schedule of Benefits, Riders and Amendments.
ScopeDescribes benefits, exclusions, limitations, member rights and responsibilities, and how to obtain services under the Policy.
Accompanying documentsCertificate is accompanied by the Schedule of Benefits, any Riders, Amendments, Notices, and the Application.
Network Coverage
In‑Network requirementCoverage is limited to Covered Health Services provided by In‑Network Providers under this EPO plan; members receive In‑Network benefits when using network providers.
Out‑of‑Network exceptionsOut‑of‑Network benefits are only available in limited circumstances (Emergency Health Services, out‑of‑area urgent care, or approved Out‑of‑Network Authorization initiated by an In‑Network Provider).
Balance billing and payment limitsWhen limited Out‑of‑Network benefits apply, payment is limited to the Maximum Allowed Amount and members may be Balance Billed for amounts above that limit.
Selected defined terms from Section 2
ADLActivities of Daily Living (ADL): basic self‑care tasks such as bathing, eating, dressing, toileting, and transferring.
APTCAdvance Premium Tax Credit (APTC): federal tax credit to lower monthly premiums when obtained through the Marketplace.
Adverse Benefit DeterminationA denial, reduction, termination, or failure to provide or pay a Benefit, including rescission of coverage.
AgentPerson or business who assists in evaluating plan options and enrolling in a Qualified Health Plan through the Marketplace.
Balance BillingWhen a Provider bills the member the difference between the Provider's billed amount and CareSource's Maximum Allowed Amount.
Maximum Allowed Amount (MAA)Plan's allowed amount for a service used to determine member cost‑sharing and provider reimbursement, referenced for OON payment limits and balance billing.
Medicare Parts A/B/C/D definitions
Medicare Parts A/B/C/DMedicare Parts A, B, C and D as defined by Title XVIII and subsequent amendments; referenced in coordination of benefits rules.
Medicare interactionWhen Medicare is primary, CareSource reduces its benefits so combined payments do not exceed Medicare Eligible Expense.
Applicability noteMedicare Benefits are determined as if Medicare Parts A and B paid even in certain situations (e.g., opt‑out providers).
Mental Health Services definition
DefinitionMental Health Services: Covered Health Services for diagnosis and treatment of Mental Illness, including evaluations, diagnostic testing, treatment planning, medication management, inpatient and outpatient modalities, residential care and crisis intervention when provided by licensed in‑network providers.
DSM noteListing in the DSM does not automatically make treatment a Covered Health Service; medical necessity and other policy provisions apply.
SettingsServices may be covered across inpatient, partial hospitalization, day treatment, intensive outpatient, residential and telehealth settings as specified.
Observation definition
Observation definitionObservation: an alternative to inpatient admission to evaluate and render medically necessary services when stay is not expected to exceed 24 hours (occasionally more).
Prior authorization thresholdObservation stays beyond 48 hours require prior authorization.
PurposeUsed to determine need for inpatient admission while providing necessary evaluation and treatment.
Out-of-Network Provider definition
Out‑of‑Network ProviderAn Out‑of‑Network Provider/Facility/Pharmacy is one which has not been selected for participation in CareSource's network.
OON AuthorizationAn Out‑of‑Network Authorization is a written request from an In‑Network Provider to have services provided by an Out‑of‑Network Provider and will not be approved if In‑Network providers can reasonably provide the same or substantially similar care.
Balance billing riskOut‑of‑Network Providers may balance bill members for amounts over the Maximum Allowed Amount except in specified emergency/ancillary situations.
Out-of-Pocket Maximum definition
Out‑of‑Pocket MaximumOut‑of‑Pocket Maximum: the maximum amount a member is required to pay for medical and Prescription Drugs in a single year; payments for non‑Covered services and amounts in excess of the Maximum Allowed Amount do not count toward the Out‑of‑Pocket Maximum.
ExceptionsFinancial assistance (coupons, savings cards, grants, gift/cash cards) generally do not count toward the Out‑of‑Pocket Maximum unless required by law.
OON payment treatmentAmounts paid when Plan reimburses an Out‑of‑Network Provider for limited Covered Health Services in excess of the Maximum Allowed Amount do not count toward the Out‑of‑Pocket Maximum.
Practitioner/Qualified Practitioner definition
Practitioner/Qualified PractitionerBroad definition including physicians, physician assistants, nurse practitioners, nurse midwives, nurse anesthetists, podiatrists, psychologists, licensed clinical social workers, chiropractors, physical therapists and others licensed/certified in the state where care is rendered and acting within scope of license.
Licensure requirementQualified Practitioners must be licensed or certified by the state in which care is rendered and perform services within their scope of practice.
Use in policiesTerm used throughout policy to identify who may deliver Covered Health Services and meet provider‑based requirements.
Prescription Drug definition
Prescription DrugPrescription Drug/Pharmaceutical Product: FDA‑approved drug/device dispensed by prescription; includes immunizations in pharmacy, inhalers, insulin, and specified diabetic supplies (test strips, meters, syringes, lancets, certain CGMs).
Formulary linkageDrugs are subject to the Prescription Drug Formulary which assigns tiers and may impose Prior Authorization, Quantity Limits, Step Therapy, or Age Limits.
Medical vs Pharmacy benefitSome drugs administered in provider settings may be covered under the Medical Benefit rather than the Prescription Drug Benefit.
Prior Authorization definition
Prior Authorization definitionPrior Authorization: determination of coverage for services made after review of an advanced written authorization with appropriate documentation; decisions are based on Medical Necessity and specified prior authorization lists.
Provider roleProviders are required to obtain Prior Authorization on behalf of members before providing listed Covered Health Services; failure to obtain may trigger penalties.
Timeline noteNon‑emergency prior authorization requests must be received at least 15 business days before the service; urgent/expedited timelines exist as described.
Skilled Nursing Facility definition
Skilled Nursing FacilitySkilled Nursing Facility: a licensed and certified facility providing continuous 24‑hour inpatient skilled nursing services; excludes facilities primarily providing behavioral health, custodial or long‑term care.
Coverage conditionsSNF benefits require services to be skilled, ordered by a Provider, and a cost‑effective alternative to inpatient hospital care.
Stay limitsCoverage includes room and board (semi‑private or private when semi‑private unavailable) up to and including 30 days per stay, with renewal rules after a 60‑day gap.
Telehealth Service definition
Telehealth ServiceTelehealth Service: virtual visit using audio‑video or audio‑only telecommunications with a qualified provider; may be referred to as E‑Visits, Video Visits, or Virtual Health.
Coverage limitsTelehealth services are covered when rendered by in‑network qualified providers but excluded or limited services remain excluded when delivered via telehealth; telephone‑only, text, email and asynchronous messages are not Covered Telehealth Visits.
Denial riskCoverage may be denied for telehealth visits that cannot reasonably be completed online (e.g., comprehensive physical exams).
Unproven/Experimental/Investigational definition
Unproven ServicesUnproven/Experimental/Investigational Services: services or medications lacking credible scientific evidence (well‑conducted RCTs or cohort studies) demonstrating measurable beneficial health outcomes and are excluded.
Evaluation processCareSource compiles and reviews clinical evidence and issues medical/drug policies that may be changed; determinations of Experimental status made at time services are incurred.
Clinical trial exceptionRoutine patient costs for qualifying clinical trials may be covered as described under Clinical Trials even if investigational.
Eligible Person, Dependent, Enrolled Dependent definitions
Eligible PersonEligible Person: an individual who may enroll under the Policy; when enrolled referred to as a Covered Person or member.
Dependent / Enrolled DependentDependent: Subscriber's legal spouse or Dependent child who lives within the Service Area; an Enrolled Dependent is a Dependent who is enrolled under the Policy.
Enrollment constraintsEligible Persons must reside within the Service Area to enroll; Special Enrollment Periods and Marketplace rules may apply to adding Dependents (e.g., newborns within 60 days).
CareSource determinations
CareSource determinations roleCareSource's determinations about Benefits are administrative decisions for payment purposes only and do not dictate clinical care decisions.
Delegation and processesCareSource may delegate discretionary authority to other entities (e.g., PBM) and may establish quantity limits and reimbursement policies.
Provider credentialingCareSource performs credentialing to confirm licenses and credentials but does not assure provider quality; providers remain independent practitioners.
In‑Network Providers definition
In‑Network ProvidersIn‑Network Providers: those contracted with CareSource to provide Covered Health Services at agreed rates; members receive In‑Network benefits when using these providers.
Member obligationMembers are responsible for verifying provider network status and obtaining Prior Authorization when required to receive In‑Network benefits.
Provider independenceIn‑Network Providers are independent contractors; CareSource is not liable for provider acts or omissions.
Balance Billing definition
Balance BillingBalance Billing: when an Out‑of‑Network Provider bills the member the difference between the Provider's billed amount and CareSource's Maximum Allowed Amount; applicable for certain limited OON services.
When allowedMembers may be Balance Billed for ground ambulance, urgent care, non‑emergency services and referrals when no payment agreement exists.
When prohibitedMembers cannot be Balance Billed for Emergency services and covered ancillary services provided at an In‑Network facility or for Emergency Air Ambulance.
Limited Covered Health Services from Out‑of‑Network Providers
Limited OON covered circumstancesLimited Covered Health Services from Out‑of‑Network Providers include Emergency Health Services, out‑of‑area urgent care while traveling, and care approved via written Out‑of‑Network Authorization initiated by an In‑Network Provider.
Authorization conditionsOut‑of‑Network Authorization must be approved by CareSource before services are rendered (except emergencies) and services must comply with Policy provisions including Prior Authorization.
Balance billing and paymentWhen limited OON coverage applies, payment is limited to the Maximum Allowed Amount and members may owe the difference (Balance Billing) unless prohibited (e.g., emergency ancillary services at In‑Network facilities).
Coverage for a Disabled Dependent Child
Disabled dependent continuationCoverage for an unmarried enrolled dependent child who is medically certified as disabled and dependent will continue beyond limiting age if proof provided; CareSource may require documentation within 31 days and periodic verification not more than once per year after two years.
Proof requirementCareSource may require a Provider chosen by CareSource to examine the child (exam paid by CareSource) and may ask for continuing proof of disability periodically.
Failure to provide proofIf proof of disability/dependency is not provided within required timeframe, coverage for the child will end.
Intensive Level Services definition
Intensive Level Services definitionIntensive Level Services: evidence‑based behavioral therapies for Autism Spectrum Disorder that address cognitive, social and behavioral deficits and may include speech and occupational therapy when concomitant with behavioral therapy.
Intensity requirementTreatment plans must include at least 20 hours per week over a six‑month period and require member engagement and specified, measurable goals with regular observation.
Coverage limitsIntensive level services are covered for up to four cumulative years; prior therapy from any payer may be credited against the four‑year allowance.
Non‑Intensive Level Services definition
Non‑Intensive Level ServicesNon‑Intensive Level Services: evidence‑based therapies provided after completion of intensive services or for members who will not receive intensive services but will benefit from non‑intensive therapy; must be delivered by qualified personnel under a measurable treatment plan.
PurposeDesigned to sustain and maximize gains made during intensive services or to improve condition when intensive services are not provided.
Provider requirementsMust be provided by qualified providers, professionals, therapists or paraprofessionals consistent with treatment plan and scope of practice.
Experimental/Investigational/Unproven definition
Experimental/Investigational/UnprovenServices or supplies lacking credible scientific evidence (well‑conducted RCTs or cohort studies) demonstrating measurable benefit are considered Experimental/Investigational/Unproven and are excluded.
Determination processCareSource will determine Experimental/Investigational status at time services are incurred and maintains processes to review clinical evidence and issue medical/drug policies.
Clinical trial exceptionRoutine patient care costs for qualifying clinical trials may still be covered as described under the Clinical Trials section despite investigational status of interventions.
Covered Behavioral Health Services definition
Covered Behavioral Health ServicesCovered Behavioral Health Services include evaluations, diagnostic testing, treatment planning, medication management, inpatient, partial hospitalization, day treatment, intensive outpatient, residential services, individual/family/group therapy, and crisis intervention when delivered by licensed in‑network providers or via telehealth.
SettingsServices may be provided in inpatient, outpatient, transitional behavioral health, residential, and telehealth settings per policy definitions.
Exclusion caveatTreatment listed in DSM does not automatically guarantee coverage; services must meet Medical Necessity and other policy requirements.
Cochlear implant — medical necessity definition
Cochlear implant medical necessityCochlear implants are Medically Necessary when used in accordance with FDA label indications for individuals with severe‑to‑profound hearing loss who receive limited benefit from hearing aids.
Post‑op therapy limitPost‑cochlear implant outpatient aural therapy limited to 30 visits per year.
Accessory exclusionsBatteries, cords and other accessories for cochlear implants may be excluded or limited.
Habilitative Services definition
Habilitative ServicesHabilitative Services: health care services that help a person keep, learn or improve skills and functioning for daily living; examples include evidence‑based PT/OT/ST provided by licensed therapists under a written treatment plan.
Annual visit limitsPhysical, occupational and speech therapy limited to 20 PT, 20 OT and 20 ST visits per year respectively (not combined with rehabilitative services).
Treatment plan requirementServices must be evidenced‑based and provided under direction of a Provider with a written treatment plan established or certified by the treating Provider.
Skilled care definition
Skilled careSkilled care: services (skilled nursing, teaching, rehabilitation) delivered or supervised by licensed technical or professional medical personnel, ordered by a Provider and not primarily custodial in nature.
Custodial exclusionCare primarily custodial or long‑term is not covered even if provided by licensed staff.
Palliative Care definition
Palliative CarePalliative Care: supportive interdisciplinary care focused on symptom management and quality of life for patients with chronic conditions; not curative and provided by an interdisciplinary team under Provider order with an in‑network hospice‑certified Provider.
Provider order requirementTo receive palliative care benefits, the Provider must order palliative care with a hospice‑certified in‑network Provider; team works with Provider for symptom management and advanced care planning.
SettingsPalliative care may be provided in home, clinic or hospital settings as appropriate.
Covered With No Cost Share
Covered With No Cost ShareCertain preventive services recommended by USPSTF, ACIP, and HRSA when provided in‑network are covered at 100% with no cost share.
Age/setting appropriatenessPreventive services must be age‑appropriate and provided in an outpatient primary care setting to qualify for no cost share.
Policy provisionsPreventive services remain subject to Medical Necessity and other Policy limitations or exclusions despite being eligible for no cost share.
Covered With Cost Share
Covered With Cost ShareSome preventive services are covered but subject to Deductible, Copayment or Coinsurance (i.e., Covered With Cost Share) depending on context and service performed.
Screening vs diagnosticIf a preventive service results in diagnostic follow‑up (e.g., polyp removal at colonoscopy), cost‑sharing may apply to the diagnostic component per policy rules.
Plan and provider settingCoverage level depends on provider setting and compliance with evidence‑based recommendations and policy provisions.
Telehealth Services (visits) definition
Telehealth VisitsTelehealth Visits are virtual visits with in‑network qualified providers using audio‑video or audio‑only systems; excluded modalities (telephone‑only, text, email, asynchronous messaging) are not Covered Telehealth Visits.
Coverage parityTelehealth visits may be covered when rendered by in‑network qualified providers, but excluded or limited services remain excluded when delivered via telehealth.
Denial considerationsCareSource may deny telehealth coverage when the visit cannot reasonably be completed using online technology (e.g., comprehensive physical exams).
Skilled care / SNF care definition
Skilled care / SNF careSkilled care/SNF care: licensed 24‑hour inpatient skilled nursing services provided in a Skilled Nursing Facility meeting medical necessity criteria and not primarily custodial in nature.
Stay and renewalsSNF coverage includes room and board up to 30 days per stay; benefit renews when there has been no inpatient hospital or SNF skilled care for 60 consecutive days.
ExclusionsCare that is primarily custodial or long‑term (even if provided by licensed staff) is not covered under SNF benefits.
Formulary definition
FormularyFormulary: list of drugs/devices categorized into tiers and subject to review and modification; determines coverage and applicable member cost‑sharing.
Formulary accessFormulary is available online at CareSource.com/Marketplace and via Member Services; providers can use the Formulary Search Tool to view limits and requirements.
Tier structureFormulary tiers (Tier 0–4) determine copay/coinsurance and supply limits (specialty drugs typically limited to 30‑day supply).
Utilization Management Controls
Utilization Management ControlsUtilization Management Controls include Prior Authorization (PA), Quantity Limit (QL), Step Therapy (ST), and Age Limit (AL) used to manage drug coverage and utilization.
Provider bypass and exception processProviders or members may request bypasses or exceptions to PA/QL/ST/AL by submitting clinical information electronically or by fax; denials are appealable.
Formulary indicatorsPA, QL, ST and AL are shown on the Formulary to indicate applicable controls for specific drugs.
Independent Review Entity (IRE) definition
Independent Review Entity (IRE)An Independent Review Entity (IRE) is an external reviewer contracted to review denied non‑formulary drug exception requests and provide determinations within stated timeframes (72 hours standard; 24 hours expedited).
External review accessMembers or authorized representatives, including providers, may request an external review of a denied drug exception and receive IRE determinations per timelines.
Expedited processExpedited reviews receive verbal notification within 24 hours; standard reviews within 72 hours of receipt.
Pharmacy Benefit Manager (PBM) definition
Pharmacy Benefit Manager (PBM)An external company that supports the plan by advising on the Formulary, helping pharmacies bill, providing formulary and cost information, operating nationwide retail, mail and specialty pharmacy networks, and offering programs to improve medication use; the PBM does not independently set benefits.
PBM functionsPBM assists with billing, formulary tools, access to lower‑cost drugs, specialty/mail order services, and programs to improve safe and effective drug use under CareSource direction.
LimitationsPBM helps implement the Prescription Drug Benefit but does not have authority to change Benefit design except as directed by CareSource.
Medication Therapy Management (MTM) definition
Medication Therapy Management (MTM)A no‑cost program encouraging pharmacist consultation to review medications, provide education, identify interactions, and find cost‑saving alternatives to improve medication use and adherence.
Pharmacist servicesPharmacists provide medication reviews, education on proper use, interaction checks, and identify opportunities to save money for members.
Voluntary participationMembers are encouraged to participate and meet with pharmacists as part of the MTM program to optimize therapy.
Primary Plan definition
Primary Plan (COB)Primary Plan: the plan required to pay first when a person is covered by more than one policy or plan; may include group/individual insurance, HMOs, Medicare, and certain other coverages as permitted by law.
Notification requirementMembers must notify CareSource if they have other coverage that constitutes a plan under coordination of benefits rules.
Primary plan exclusionsCertain limited coverages (hospital indemnity, accident only, specified disease, Medicaid, etc.) are not considered Primary Plans for COB purposes.
Allowable Expense definition
Allowable ExpenseAllowable Expense: a health care expense (including Deductibles, Copayments, Coinsurance) that is covered at least in part by any Primary Plan and by CareSource when coordinating benefits.
Non‑allowable amountsExpenses not covered by any plan or amounts prohibited by law/contract are not Allowable Expenses (e.g., amounts in excess of highest negotiated fee when plans differ).
Service‑based valuationWhen a plan provides benefits in the form of services, the reasonable cash value of each service is considered an Allowable Expense.
Interpretation of benefits
Benefit interpretation discretionCareSource has sole discretion to interpret Benefits, contract terms, make factual determinations, and may delegate this authority to other entities for administration.
Amendment practiceCareSource may in its discretion offer Benefits for services that would otherwise not be Covered; such decisions do not create precedent for similar cases.
Policy controlCareSource's interpretation governs how Policy provisions are applied, including limits, exclusions and administrative rules.
Policy Summary
PayerCareSource
PolicyCertificate of Coverage (CareSource)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionProviders must obtain Prior Authorization on behalf of members before delivering Covered Health Services that require it.
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.