CareSource EPO Coverage Prior Auth Policy Update

inv-01: In-Network Coverage and Out-of-Network Exceptions

Coverage is limited to Covered Health Services provided by In‑Network providers, with limited exceptions for out‑of‑network care.

Covered Health Services must be provided by In‑Network Providers except in limited circumstances described in the policy (Emergency Health Services, out‑of‑service‑area urgent care, or CareSource‑approved Out‑of‑Network Authorizations).

Out‑of‑Network services are generally not covered and member is responsible for charges when services are provided by Out‑of‑Network Providers unless an exception applies.

When limited Out‑of‑Network coverage applies, payment is limited to the Maximum Allowed Amount (or Qualifying Payment Amount where applicable) and members may be responsible for any difference charged by the Out‑of‑Network Provider (balance billing) except where law limits balance billing for emergency services.

An In‑Network Provider must obtain and submit a written Out‑of‑Network Authorization to CareSource and receive approval before Out‑of‑Network services are rendered; failure to obtain an approved Out‑of‑Network Authorization (except for Emergencies) will result in no payment.

inv-02: Covered Services and Limitations (overview)

Covered services are those that are Medically Necessary, provided while policy is in effect, and generally delivered by In‑Network providers; benefits are subject to cost‑sharing and plan limits.

Covered Health Services must be Medically Necessary and not Experimental/Investigational (except as expressly provided for qualifying clinical trials).

Benefits are available only while the Policy is in effect and only for Covered Persons who meet eligibility requirements; benefits are subject to Deductible, Copayment, Coinsurance and any visit or dollar limits in the Schedule of Benefits.

Prior Authorization requirements, network status, and benefit limits affect coverage determinations; Prior Authorization does not guarantee payment and required requests must follow timing rules in the policy.

inv-03: Coverage-related definitions and member financial obligations (partial)

Key coverage definitions and member financial obligations that affect access and responsibility.

Maximum Allowed Amount (MAA) defines the plan's payment basis; for Out‑of‑Network Providers it is a rate similar to what would have been paid to a contracted provider in the region; Qualifying Payment Amount (QPA) applies where specified (e.g., No Surprises Act situations).

Prior Authorization is a coverage determination based on Medical Necessity after review of an advanced written authorization with supporting documentation; failure to obtain required Prior Authorization may result in penalties as described in the policy.

Premium payment grace periods affect continuity of coverage (see premium rules); members remain responsible for applicable cost‑sharing and for charges from providers when services are non‑covered or when balance billing applies.

inv-04: Premium payment and grace period criteria

Premium payment and grace period rules that determine termination and backdating of coverage.

If member does not receive an Advance Premium Tax Credit (APTC): a 31‑day grace period applies; failure to pay within this period may result in termination effective the last day of the last month for which premium was received.

If member receives an APTC: a three‑month grace period applies; if premiums remain unpaid at the end of that period, coverage terminates as of the last day of the first month of the three‑month grace period.

Payments mailed may require up to seven days to process and acceptance of premium payments after termination does not automatically reinstate coverage absent compliance with policy conditions.

inv-05: Enrollment, special cases, and termination criteria

Enrollment, special enrollment events, and events causing termination of coverage.

Enrollment occurs during Open Enrollment or a qualifying Special Enrollment Period; Effective Date depends on enrollment type and is listed on the member's ID card.

Newborns must be reported and required premium paid within 60 days to continue coverage; Marketplace enrollments follow Marketplace rules for dependents.

Coverage may end for reasons including failure to pay premiums (per grace period rules), fraud or material misrepresentation (with special rules for first two policy years), the entire policy ending, loss of eligibility (coverage ends last day of calendar month of ineligibility), or moving out of the Service Area (coverage ends 60 days after move).

If a person is hospitalized when coverage begins, CareSource will pay for Covered Health Services from the first day of coverage if notified within 48 hours (or as soon as reasonably possible).

inv-06: Network and Coverage Criteria

Network and coverage rules governing in‑network primacy, limited out‑of‑network circumstances, continuity of care, and ID card requirements.

In‑Network Providers are the required source for Covered Health Services; benefits are provided when services are obtained from In‑Network Providers and CareSource determines coverage based on this Certificate and Medical Necessity determinations.

Limited exceptions: Out‑of‑Network coverage is available only for Emergency Health Services, medically necessary urgent care while out of service area, and CareSource‑approved Out‑of‑Network Authorizations initiated by an In‑Network Provider; follow‑up care must be with In‑Network Providers.

An In‑Network Provider must obtain an Out‑of‑Network Authorization and receive CareSource approval before Out‑of‑Network services are rendered; without prior approved authorization (except emergencies) no payment will be made and penalties may apply.

Members have continuity‑of‑care rights: PCPs who terminate without cause may be continued through the policy year at in‑network benefit levels; non‑PCP providers may be continued up to 90 days or until end of course of treatment or policy year (whichever is shorter); special rules apply for pregnant members in their third trimester.

inv-07: Coverage criteria and program-specific rules

Coverage is conditional on Medical Necessity, provider network status, prior authorization timelines, and program‑specific requirements and limits.

Covered Health Services must be Medically Necessary, not Experimental/Investigational, provided while Policy is in effect, and generally provided by In‑Network Providers unless limited exceptions apply.

Prior Authorization timing: non‑emergency requests must be received at least 15 business days before service; urgent/emergency hospital admission notification required within 48 hours after admission or as soon as medically able; Prior Authorization does not guarantee payment.

If a Provider fails to obtain required Prior Authorization, the member may be responsible for a penalty (specified elsewhere in the policy).

Program‑specific rules (examples): intensive autism services require evidence‑based treatment per a defined plan (average ≥20 hours/week over six months, begun after diagnosis, typically ages 2–9) and are limited to up to four cumulative years; ambulances, behavioral health services, and transplantation services have specific provider, facility and prior authorization requirements per the policy.

inv-08: Coverage Criteria and Exclusions (behavioral health and SUD services)

Behavioral health, SUD, selected therapeutic and procedural coverage, with stated exclusions and limitations.

Behavioral Health Services (Mental Health) covered when provided by licensed in‑network professionals (inpatient, outpatient, partial hospitalization, day treatment, intensive outpatient, residential, telehealth), including evaluations, diagnostic testing, treatment planning, medication management, therapy, and crisis intervention.

Substance Use Disorder Services covered across levels of care (including detox, inpatient, day treatment, partial hospitalization, IOP, residential, MAT/methadone maintenance) when provided by appropriate licensed providers.

Behavioral health exclusions: Not covered: treatment for behavioral issues without a clinical mental health diagnosis (e.g., uncomplicated bereavement, codependency, occupational or marital problems), services extending beyond medically necessary period, custodial or long‑term care, school‑based tuition under IDEA, and non‑evidence‑based or experimental therapies listed in the policy.

Psychological testing not likely to yield information useful for ongoing medical treatment (custody, vocational, academic assessments) is excluded.

inv-09: Contraceptive coverage

Coverage for FDA‑approved contraceptives and related services; preventive contraceptives on the formulary provided without member cost‑sharing.

Coverage includes FDA‑approved contraceptive drugs and devices; medical services necessary to prescribe, administer, maintain, or remove contraceptives are covered.

Contraceptives designated as Preventive on the Prescription Drug Formulary are dispensed at no cost to the member per the policy's preventive services rules.

inv-10: Dental coverage and accident-only provisions

Dental coverage is limited to medical‑related dental care and accidental dental injuries; routine dental services are excluded except as specified.

Covered dental services are limited to oral exams, X‑rays, extractions and non‑surgical elimination of oral infection when directly treating a covered medical condition (e.g., acute trauma, cancer, cleft palate, transplant prep, pre‑immunosuppression).

Excluded dental services: Routine dental care (preventive care, endodontics, periodontal surgery, restorative treatment, braces, elective procedures) is not covered except as related to trauma or specified medical conditions.

Accident‑only dental coverage requires treatment by a DDS/oral surgeon within 72 hours of the accident (extensions possible within 60 days for extenuating circumstances), treatment started within three months unless extenuating circumstances, and completion within 12 months; specified accident‑related procedures are covered.

inv-11: DME and supplies coverage and exclusions

Durable medical equipment (DME), diabetes supplies, repair/replacement rules, and excluded items.

DME and diabetes supplies (insulin, test strips, lancets, syringes, certain CGMs, infusion devices) are Covered when prescribed by an In‑Network Provider and obtained from an In‑Network DME provider; quantity limits may apply.

CareSource may decide whether to rent or purchase DME; repairs and replacements are covered except for lost/stolen items or damage due to misuse, malicious damage, or gross neglect.

DME exclusions: Excluded items include many comfort/convenience devices, cranial helmets, certain phototherapy beds, non‑prescription OTC items (except specified diabetes supplies), devices used for sports, communication devices except specific speech aids, and routine maintenance of equipment.

inv-12: Emergency services coverage

Emergency services are covered whether rendered by in‑ or out‑of‑network providers for stabilization; observation stays covered up to 48 hours without prior authorization.

Medically necessary Emergency Health Services are covered when rendered by In‑Network or Out‑of‑Network Providers; emergency services rendered out‑of‑network are covered at the network rate subject to the Qualifying Payment Amount and members cannot be balance billed beyond the QPA for emergency services.

Observation stays are covered up to 48 hours without prior authorization; prior authorization is required for observation stays beyond 48 hours.

inv-13: Habilitative therapy limits

Habilitative services are covered when evidence‑based and under a written treatment plan; visit limits apply.

Habilitative services (evidence‑based PT, OT, ST) covered when provided by appropriately licensed therapists under a written treatment plan and directed by a Provider.

Visit limits: up to 20 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per year; these are separate from rehabilitative service limits.

inv-14: Hearing services and hearing aid limitations

Hearing services include diagnostic testing and hearing aids with frequency limits and accessory exclusions.

Coverage includes diagnostic testing, treatment of hearing impairment from injury/illness, surgery to repair anatomic hearing disorders, and hearing aids for persons certified as deaf or hearing impaired by a Provider or audiologist.

Hearing aid limits: one hearing aid per ear every 36 months; batteries, cords and accessories are excluded; bone‑anchored hearing aids covered only for specific severe conditions and limited replacements per policy rules.

inv-15: Home health coverage and limits

Home health services covered when ordered by a Provider and meet skilled‑care criteria; annual visit limits apply.

Home health services are Covered when ordered by a Provider, provided by an in‑network licensed or Medicare‑certified Home Health Agency, would otherwise require hospital/SNF confinement, provided on a part‑time or intermittent skilled schedule, and are not custodial.

Home health benefit limits: limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one home health visit; services by nursing assistants/personal care workers are excluded.

inv-16: Hospice coverage

Hospice care is covered for terminally ill members under an approved plan when eligibility criteria are met.

Hospice benefits are available when recommended by a Provider and the patient is certified by the attending Provider (and hospice medical director) as having a life expectancy of one year or less.

Hospice services include interdisciplinary team care, skilled nursing, short‑term inpatient respite, social work counseling, PT/OT/ST, dietary support, and pharmaceuticals/equipment necessary for palliation when part of an approved treatment plan.

Palliative care must be ordered by a Provider and delivered by an in‑network hospice‑certified Provider; palliative care focuses on symptom management and quality of life rather than cure.

inv-17: Covered and Non-Covered Service Criteria (excerpt)

Summary of covered services and common limits or exclusions across multiple service categories.

Home health visits limited to 60 per calendar year; up to 4 consecutive hours of skilled care equals one visit.

Hospice eligibility requires life expectancy ≤1 year confirmed by attending Provider and hospice medical director; hospice covers interdisciplinary and palliative services as part of an approved plan.

Inpatient rehabilitation requires ability to participate and typically a minimum of three hours per day for five days per week with Provider visits at least three times per week.

Maternity/newborn protections include minimum hospital stay of 48 hours for vaginal delivery and 96 hours for cesarean delivery unless attending Provider and mother agree to earlier discharge.

Enteral/parenteral nutrition covered when product is a medical food, is the primary source of nutrition (>50%), labeled for the specific condition, and used under Provider or RD supervision.

inv-18: Summary coverage criteria

High‑level summary of selected service categories and limits.

Podiatry services covered for treatment of foot disorders related to disease, injury or defect; routine foot care generally excluded except for members with systemic conditions (e.g., diabetes, peripheral vascular disease) that compromise neurovascular integrity.

Outpatient rehabilitation visit limits: PT/OT/ST limited to 20 visits/year each; cardiac and pulmonary rehab limited to 36 visits/year; cognitive rehab limited to 20 visits/year when medically necessary after TBI or stroke.

Skilled Nursing Facility stays covered up to 30 days per stay when medically necessary; SNF benefit renews after 60 consecutive days without inpatient/skilled care for same diagnosis.

Prosthetic devices covered when ordered by a Provider and replacing a non‑functional body part; CareSource pays for a device meeting minimum specifications and member pays for enhancements or upgrades beyond that specification.

Telehealth services covered when delivered by in‑network Providers; excluded modes include telephone‑only, text, email, EHR messaging and remote patient monitoring as specified.

inv-19: Extracted coverage and exclusion criteria (partial)

Partial extraction of coverage and exclusion rules for select clinical areas and administrative processes.

Temporomandibular disorder (TMD) surgical and non‑surgical treatments covered when radiographic evidence demonstrates significant joint abnormality, cause is congenital/developmental/acquired/injury, and procedures are reasonable and appropriate to control infection/pain/dysfunction.

Transplant services covered when ordered by a Provider at Designated Facilities/Providers or Centers of Excellence; donor costs payable only if transplant recipient is a Covered Person; prior authorization required; experimental or non‑human/artificial organ transplants are excluded.

Therapeutic treatments such as dialysis, intravenous chemotherapy/infusions, and radiation oncology are covered when medically necessary; transfusions/infusions must be provided in the most cost‑effective setting and meet medical necessity.

Prescription drug benefit is formulary‑guided: coverage depends on formulary status, PA, QL, ST designations; prior authorization and quantity/step limits apply; specialty/mail order rules and direct claim windows apply as specified.

inv-20: Non‑Formulary Exception and Review Criteria

Process and timelines for non‑formulary (drug exception) requests and external review.

Members or Providers may request a non‑formulary drug exception (Member Exception Request Form or via Member Services); requests may be submitted by authorized representatives with consent.

If a drug exception is granted, the non‑formulary drug is treated as an Essential Health Benefit subject to applicable cost‑sharing and counts toward the Annual Out‑of‑Pocket Maximum.

Timelines: standard/formulary and non‑formulary determinations follow specified timeframes; external independent review entity (IRE) decisions on denied exception requests are provided within 72 hours (or 24 hours if expedited) per policy procedures.

A granted exception does not override member eligibility, plan exclusions, or other plan coverage requirements; denials include instructions for requesting independent external review.

inv-21: Non-Covered Items and Services

Section identifying items and services that are not covered under the prescription drug and general exclusions sections.

Prescription drug exclusions: Examples of excluded prescription drugs/devices include those for appetite suppression/weight loss as primary diagnosis, hyperhidrosis, sexual dysfunction for primary diagnosis, cosmetic uses, onychomycosis, growth hormone for familial short stature, experimental uses, and natural/homeopathic remedies unless deemed medically necessary.

Section 9 lists general exclusions and clarifies that CareSource will not pay for services described as exclusions even if recommended by a Provider or if they are the only available treatment; policy headings do not expand or limit exclusions beyond the stated text.

inv-22: Coordination / Order of Benefits Criteria

Order of Benefit Determination rules applied when a person is covered by multiple plans.

The Primary Plan pays first according to its terms without regard to other plans; a plan that is primary pays benefits without considering other plans unless it is secondary by the rules.

Dependent child order: for children of married/cohabiting parents, the plan of the parent whose birthday falls earlier in the calendar year is primary (tie‑breakers described); for divorced/separated parents, court decrees or specified rules govern order of benefits.

Active employee coverage is primary over retired/laid‑off employee coverage; COBRA/state continuation is secondary to plans covering a person as an employee or dependent.

If preceding rules do not determine order, allowable expenses are shared equally and this plan will not pay more than it would have as the primary plan; members must provide information needed to apply COB rules and failure may delay or deny claims.

inv-23: Coverage-related administrative provisions

Administrative provisions that affect coverage operations, utilization review, second opinions, and statutory protections.

One second opinion per injury or illness from an In‑Network Provider is covered; prior authorization is required when specified in Section 6; out‑of‑network second opinions require an Out‑of‑Network Authorization.

Federal law guarantees minimum hospital stay protections for childbirth (48 hours vaginal, 96 hours cesarean); issuer may not require authorization for stays up to these lengths and cannot treat later portions of the stay less favorably.

CareSource may require utilization management activities (ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review) at CareSource expense to determine if a service is a Covered Health Service.

Providers and members must follow prior authorization rules and timing; failure to obtain required prior authorization can result in penalties per the policy (member penalty referenced elsewhere).

Coding, Billing and Code-level Guidance

Prescription Drug / Specialty Drugmixed

Prescription Drug List tiers and specialty drug designation; list is periodically reviewed (generally quarterly).

Coding references for reimbursementmixed

CPT	Reference to Current Procedural Terminology used in reimbursement determinations

Reimbursement determinationmixed

Eligible Expenses and Maximum Allowed Amount determinations per CareSource reimbursement policy

Prior authorization service listmixed

Reference to complete list of services requiring prior authorization available at CareSource website (CareSource.com/mp-WI-pa)

Cochlear Implant Coding GuidancemixedCovered

	Cochlear implants deemed Medically Necessary when used in accordance with FDA label indications
	Outpatient rehabilitation/post-cochlear implant aural therapy limited to 30 visits per year (limitation referenced)

DME and diabetes supplies (descriptive)mixed

Insulin, diabetes drugs, test strips, lancets, syringes, certain continuous glucose monitors, insulin infusion devices and related DME when included on Prescription Drug List and prescribed by an In-Network Provider

Infusion/Clinic-administered PharmaceuticalsmixedCovered

No codes listed

Outpatient surgery billingmixed

Facility charges and supply charges for medically necessary outpatient surgery; provider services billed separately per Provider Fees for Surgical and Medical Services

Vision benefits (pediatric)mixedCovered

One annual eye exam and one pair of eyeglasses per calendar year for children through end of month they turn 19; eyeglass lenses and basic frames covered once every 12 months; exclusions for adult eyeglass costs, implantable lenses for refractive error, refractions and refractive surgery.

General coding notemixed

CareSource contact and administrative information (CareSource marketplace contact information)

Prescription Drug ExclusionsmixedNot Covered

Drugs or devices excluded: appetite suppression/weight loss as primary diagnosis; hyperhidrosis; sexual dysfunction as primary diagnosis; cosmetic uses; onychomycosis; drugs with therapeutically equivalent active ingredients available in another covered drug; experimental/investigational uses; and others listed in Section 9.

Allowable Expense definitions and exclusionsmixed

Allowable Expense defined as health care expense covered at least in part by any Primary Plan and CareSource policy; examples of non-Allowable Expenses include private room differential, amounts above highest negotiated fee, and benefit reductions due to failure to comply with plan provisions.

rebatesmixed

CareSource may receive rebates for certain drugs administered in home, office, or hospital; rebates are not passed to members nor applied to deductibles or copayments.

In-network requirement

RequirementCovered Health Services must be provided by an In-Network Provider under this EPO plan; In-Network Providers accept CareSource contracted rates and may only bill members for applicable Deductible, Copayment, and Coinsurance.

ExceptionOut-of-Network care is generally not covered except for Emergency Health Services, out-of-service-area Urgent Care, or limited Out-of-Network Authorizations approved by CareSource.

Billing implicationWhen limited Out-of-Network benefits apply, payment is limited to the Maximum Allowed Amount and the member may be responsible for any difference charged by the Out-of-Network Provider (Balance Billing).

Out-of-Pocket Maximum applicability

DefinitionOut-of-Pocket Maximum is the maximum amount a member must pay for medical and prescription drugs in a year; amounts for non-covered services and amounts in excess of the Maximum Allowed Amount do not count toward the Out-of-Pocket Maximum.

Non-creditable itemsAmounts paid for non-Covered services, including amounts above the Maximum Allowed Amount, and certain financial assistance (unless required by law) are excluded from the Out-of-Pocket Maximum.

Out-of-network paymentsWhen the Plan pays an Out-of-Network Provider for limited covered services, amounts paid in excess of the Maximum Allowed Amount do not count toward the Out-of-Pocket Maximum.

Prior Authorization penalty

Member penaltyIf a Provider fails to obtain required Prior Authorization, the member may be responsible for a penalty equal to 50% of the charge up to a maximum of $1,500 per Covered Health Service.

Prior Authorization timingNon-emergency Prior Authorization requests must be received at least 15 business days before the service; urgent/emergency hospital admissions require notification within 48 hours or as soon as medically able.

Authorization does not guarantee paymentPrior Authorization is a determination of Medical Necessity based on submitted clinical information but does not guarantee payment if billed services differ from authorized services or policy conditions are not met.

Autism intensive therapy intensity threshold

Intensity thresholdIntensive-level autism services are defined as evidence-based behavioral therapy averaging 20 or more hours per week over a continuous six-month period.

Age and duration limitsTreatment generally commences after age 2 and before age 9 (exceptions for medical necessity) and intensive services are covered for up to four cumulative years, with prior services credited toward the four-year limit.

Clinical requirementsServices must be delivered per a treatment plan by qualified intensive-level Providers, include direct observation at least once every two months, and involve training/consultation and family/support system participation.

Post-cochlear implant aural therapy visit limit

Visit limitOutpatient rehabilitation services for post-cochlear implant aural therapy are limited to 30 visits per year.

Accessory exclusionBatteries, cords and other accessories for cochlear implants are not covered.

Related DME ruleSpeech aid devices are covered under Durable Medical Equipment rules which may require rental vs. purchase determinations by CareSource.

Speech aid device rental requirement

Rental prerequisiteBenefits for purchase of speech aid devices and trachea‑esophageal voice devices are available only after completing a required three‑month rental period.

Provider and network requirementDurable Medical Equipment, including speech devices, must be prescribed by an In‑Network Provider and obtained from an In‑Network DME provider.

Repair/replacement limitsRepairs and replacements are covered except for lost/stolen items or damage due to misuse, malicious breakage, or neglect; CareSource may decide whether to rent or purchase equipment.

Enteral/Parenteral Nutrition Criteria

Product requirementsEnteral/parenteral nutrition products must be medical foods labeled for dietary management of a specific medical disorder and used under Provider or registered dietician supervision.

Primary nutrition sourceThe product must be the primary source of nutrition, providing more than half of the individual's nutritional intake.

Weaning preference and limitsWhen medically appropriate, introduction to oral nutrition is preferred and enteral/parenteral feeding should be weaned; CareSource may establish reasonable quantity limits for supplies and equipment.

Prosthetic cost liability

Payer liabilityCareSource will pay only for a prosthetic device that meets the minimum specifications determined to meet the member's functional needs; if a member purchases a device exceeding those specifications, CareSource pays only the amount for the device meeting minimum specifications and the member is responsible for the cost difference.

Ordering requirementThe prosthetic device must be ordered or provided by, or under the direction of, a Provider.

Selection and rental vs purchaseIf more than one prosthetic device meets functional needs, Benefits are available only for the device that meets minimum specifications; CareSource may decide whether to rent or purchase.

Formulary controls

Controls used on the formularyFormulary controls include Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), and Age Limits (AL) as indicated on the Prescription Drug Formulary.

Bypass and exception processProviders may request PA approvals or bypass QL/ST/AL limits by submitting clinical information electronically or by fax; denials can be appealed and may proceed to external review per procedures.

Formulary tiers and supply limitsFormulary is organized into five tiers (including specialty drugs) and specialty drugs are generally limited to a 30‑day supply unless otherwise specified; Tier 0 drugs may be covered with no member cost when preventive by law.

Quantity and supply thresholds

Quantity limitsQuantity Limits (QL) may restrict how much of a drug may be dispensed at one time or over a timeframe; CareSource will place QL entries on the Formulary to align with FDA‑approved dosing and safety.

Specialty drug supplySpecialty drugs (Tier 4) are typically limited to a 30‑day supply at a time and must be filled by a specialty pharmacy as required by the plan.

Bypass requestsIf a higher quantity or exception is clinically needed, the Provider can request a bypass electronically or by fax; coverage for amounts above limits is not provided until approved.

Provider Responsibilities, Prior Authorization and Utilization Rules

Prior Authorization

Prior Authorization Requirement

Benefits may be reduced or excluded if Prior Authorization (PA) is not obtained when required. Prior Authorization is a determination based on Medical Necessity and is not a guarantee of payment. Providers must follow CareSource prior authorization and out-of-network authorization processes; failure to comply may result in denied or reduced Benefits and member financial penalty.

Providers must submit Prior Authorization requests on behalf of members for Covered Health Services listed on the CareSource Prior Authorization list (available at CareSource.com/mp-WI-pa or via Member Services at 877-514-2442).
Out-of-Network care: An In-Network Provider must complete and submit an Out-of-Network Authorization that CareSource must approve before services are rendered; if not followed, Benefits will not be payable.
Prior Authorization timeline (non-emergent/non-urgent): requests must be received at least 15 business days prior to the anticipated service/procedure date.
Hospital admissions (urgent/emergency): admission notification must be provided within 48 hours after admission or as soon as medically able; notification does not guarantee approval of services.
If additional care or an extension beyond the originally authorized services/time is needed, the Provider must request an extension; extensions are determined using Medical Necessity criteria.
If the Provider fails to obtain Prior Authorization when required, the member may be responsible for a penalty of 50% up to $1,500 per Covered Health Service.
Prior Authorization applies whether CareSource is primary or secondary insurer, unless CareSource is secondary to Medicare.
Prior Authorization determinations are based on the clinical information submitted by the Provider at the time of request; CareSource will pay only for services actually delivered that match the authorization.
For drugs/devices on the Formulary with PA, the Provider must submit the required supporting information electronically or via fax; PA may be required for opioid analgesics and other controlled substances.
Providers may request limit bypasses (e.g., quantity limit, step therapy, age limit) for prescription drugs by sending a request electronically or by fax; coverage is not provided until CareSource approves the bypass.
Out-of-Network Providers performing Emergency Health Services will be paid the Qualifying Payment Amount and may balance bill if allowed by law; for non-emergent out-of-network services, the Out-of-Network Authorization process must be completed beforehand.
CareSource may establish reasonable quantity limits for supplies, equipment, or appliances; Providers must follow ordering/certification requirements for items such as prosthetics (must be ordered/provided by or under direction of a Provider).
Hospice/palliative care: To receive hospice Benefits, the Provider and hospice medical director must certify terminal prognosis (generally ≤ 1 year) and the hospice must maintain a written plan of care; Provider must order hospice/palliative services and consult in treatment planning.
Dental accident timing: initial contact with a Provider/dentist must occur within 72 hours of the accident (extensions may be requested within 60 days if extenuating circumstances exist). Treatment must start within 3 months and be completed within 12 months unless extenuating circumstances apply.
Transplants, certain high-cost drugs, and other specified services require Prior Authorization and must be performed at designated facilities/providers (e.g., Centers of Excellence) per CareSource guidelines.
Providers should verify authorization status by calling 877-514-2442 to determine whether a PA request has been received, approved, denied, or is pending.

Note

Benefit Determination and Network

CareSource makes the final administrative determination of Benefits for claims, applying network status, authorizations, limitations, exclusions, and clinical criteria. CareSource may delegate administrative authority to other entities and may change service providers or network participation at its discretion.

In determining Benefits, CareSource will review Provider network status, existing authorizations, and applicable limitations and exclusions.
CareSource may require cooperation from members and Providers and may deny or delay claims if required information is not provided.
When services are rendered In-Network, members generally should not submit claims; Out-of-Network payments are limited and payable only in specified circumstances.

Note

Primary vs Secondary Payment Rule and Effect on CareSource Benefits when Secondary

When a member has more than one policy, CareSource follows coordination of benefits and order of benefit determination rules. CareSource may reduce its Benefits so total payments from all plans do not exceed the Allowable Expense.

Primary Plan: the plan required to pay first. Examples include group or individual insurance, Medicare (when primary), and others as defined in the policy.
If CareSource is secondary, CareSource will calculate what it would have paid absent other coverage and apply that amount to unpaid Allowable Expenses, then reduce payment so combined payments do not exceed the Allowable Expense.
Members must notify CareSource of any other coverage and must provide information needed to adjudicate claims. Failure to supply needed information may result in delays or denial of claims.
CareSource may obtain or share necessary facts with other organizations or persons without consent to apply coordination of Benefits rules.

Note

Clinical Trial Participation — Routine Care Coverage

Routine patient care costs incurred during participation in qualifying in-network clinical trials are Covered Benefits when trial and participant meet qualifying criteria. Coverage includes tests and services necessary to monitor the trial.

To qualify, the member must be eligible for the trial per protocol and the referring participating Provider must conclude participation is appropriate (or the member/Provider must provide medical/scientific documentation demonstrating appropriateness).
Qualifying clinical trials include those approved/funded by specified federal agencies or conducted under an FDA investigational new drug/device application, or certain exempt drug trials.
Routine costs covered include laboratory, radiologic, and other testing necessary to monitor the trial when provided in-network.

Documentation Required

Dental Accident Timing Requirements

Dental services for accidental injury are limited and time-sensitive. To be covered, treatment must be for accidental damage and provided by an appropriate dental or medical provider.

Initial contact with a Provider or dentist must occur within 72 hours of the accident. An extension may be requested within 60 days if extenuating circumstances exist due to injury severity.
Treatment must be started within three months of the accident unless extenuating circumstances exist and must be completed within 12 months of the accident.
Covered services for accidental dental injury are limited to emergency exam, diagnostic x-rays, temporary splinting, endodontic treatment, extractions, maxillofacial surgery for fractures, anesthesia, post-traumatic crowns when clinically acceptable, and replacement of lost teeth due to the injury.

Prior Authorization

Certification & Ordering Requirements for Hospice/Palliative Care

Hospice and palliative care have ordering and certification requirements to ensure eligibility for Benefits.

To receive hospice Benefits, the attending Provider and the hospice medical director must certify that the patient is terminally ill with a life expectancy of one year or less.
The Provider must consent to care by the hospice and be consulted in the development of the hospice treatment plan; the hospice must maintain a written treatment plan on file.
Palliative care must be ordered by a Provider and hospice-certified Provider involvement is required; palliative services are subject to network participation requirements (in-network hospice-certified Providers).

Documentation Required

Prosthetics Ordering Requirement

Prosthetic devices are covered only when ordered or provided by, or under the direction of, a Provider and limited to external devices or those considered Medically Necessary.

Benefits apply to external prosthetic devices; some fully implanted devices may be excluded if not Medically Necessary.
If multiple prosthetic devices can meet functional needs, CareSource covers only the device that meets minimum specifications; member is responsible for any cost difference if a higher-spec device is chosen.

Billing Rule

Prior Authorization / Limit Bypass Requests

Requests to bypass quantity, step therapy, age, or other formulary limits (Limit Bypass Requests) must be submitted by the Provider and approved by CareSource before coverage is provided.

The Formulary shows limits as PA, QL, ST, or AL. Providers can view required information via the Provider Formulary Search Tool and submit bypass requests electronically or by fax using forms on the website.
An approved bypass request is not a guarantee of payment — the drug/product must be a Covered Service, the member must be eligible, and it must not be excluded under the Plan.
If CareSource denies a bypass request, the Provider/member may appeal per the Appeals, Grievances, and Independent External Review procedures.

Documentation Required

Information Cooperation Requirement

Providers and members must cooperate and provide information needed for CareSource to determine Benefits, apply coordination of Benefits rules, and adjudicate claims.

CareSource may request and exchange necessary facts with other organizations or persons without the consent of the Covered Person to apply coordination rules and determine Benefits.
Each person claiming Benefits must provide facts needed to apply rules; failure to provide required information may result in claim delay or denial.
Providers should verify authorizations and provide complete clinical information at the time of Prior Authorization requests to avoid denials based on mismatched billed services.

Definitions and Term Clarifications

Certificate

Document roleCertificate of Coverage: the legal document that is part of the Policy and describes benefits, limitations, exclusions, and member/provider responsibilities between CareSource and the Covered Person.

ComponentsThe Policy includes this Certificate, the Schedule of Benefits, any Amendments and Riders, Notices, and the member's Application.

Effective timing noteCoverage under the Policy begins at 12:00 midnight on the Effective Date shown on the member ID card and ends at 11:59 pm on the termination date.

EPO / In-Network Requirement

Plan typeExclusive Provider Organization (EPO): Covered Health Services must be provided by In‑Network Providers except for limited circumstances such as Emergency Health Services or authorized Out‑of‑Network care.

Network billingIn‑Network Providers accept contracted rates and should not balance bill members for Covered Health Services beyond applicable cost‑sharing.

Out‑of‑network exceptionsOut‑of‑Network services are payable only in specified limited circumstances and require authorization when applicable; members may be responsible for differences between charges and the Maximum Allowed Amount.

Covered Health Service(s)

Covered Health Service(s)Services, supplies, or pharmaceuticals that are Medically Necessary, described as covered in Section 7 and not excluded in Section 9, and provided to prevent, diagnose or treat sickness, injury, mental illness, or substance use disorders.

Benefit conditionsCoverage is subject to policy conditions including Medical Necessity, provider network status, applicable limits, and that services are received while the Policy is in effect.

Documentation requirementProper proof of loss (claims and clinical documentation) must be submitted for coverage and Benefits; Prior Authorization may be required for specified services.

Medically Necessary

DefinitionMedically Necessary services are those needed to prevent, diagnose, or treat a condition and that are consistent with accepted standards of medical practice, clinically appropriate in type/frequency/duration, not primarily for convenience or cosmetic purposes, and not Experimental/Investigational.

Decision basisCareSource determines Medical Necessity using credible scientific evidence, specialty society recommendations, prevailing clinical opinion, or expert consultation at its discretion.

Payment implicationA Provider's prescription or recommendation alone does not make a service Medically Necessary or guarantee payment; the least costly effective alternative should be used to meet Medical Necessity criteria.

Maximum Allowed Amount (MAA)

MAA definitionMaximum Allowed Amount (MAA) is the maximum amount CareSource will pay for a Covered Health Service; for In‑Network Providers it is the contracted amount; for Out‑of‑Network Providers it is a rate similar to what would have been paid to a contracted provider in the region.

Balance billing linkAmounts above the MAA charged by Out‑of‑Network Providers may be billed to the member (Balance Billing) unless otherwise protected by law (e.g., QPA/No Surprises Act situations).

Payment cap effectPayments are limited to the MAA; services billed above the MAA do not count toward the member's Out‑of‑Pocket Maximum.

Out-of-Network Authorization

When requiredOut‑of‑Network Authorization and Prior Authorization must be obtained by the Provider before services are rendered for Out‑of‑Network care or for services listed on the Prior Authorization list; failure may result in denial or penalties.

Submission timingNon‑emergency Prior Authorization requests must be received at least 15 business days before the service; urgent/emergency notifications for hospital admissions must occur within 48 hours after admission or as soon as medically able.

No guaranteeObtaining Prior Authorization is a determination of Medical Necessity but does not guarantee payment if billed services differ from the authorization or other policy conditions are not met.

Pharmacy Benefit Manager (PBM)

RolePharmacy Benefit Manager (PBM) is the organization that administers pharmacy benefits, including retail, mail, and specialty pharmacy networks on behalf of CareSource.

ServicesThe PBM manages the Prescription Drug Formulary, claims processing, specialty/mail order fulfillment, and related pharmacy administrative functions.

Member contactMembers can contact Member Services for PBM‑related inquiries and formulary information via the phone number on their ID card or the CareSource website.

Prior Authorization

DefinitionPrior Authorization is the pre‑service determination of coverage for specified services based on Medical Necessity after review of an advanced written authorization with appropriate documentation.

Provider responsibilityYour Provider must request Prior Authorization on your behalf before you receive covered services listed on the Prior Authorization list; failure to obtain may trigger penalties or denial.

Timing and limitsNon‑emergency requests require 15 business days' lead time; urgent/emergency hospital admission notifications must occur within 48 hours of admission.

Urgent Care Center

DefinitionUrgent Care Center: a facility that provides unscheduled, walk‑in urgent care services; it is not a regular provider office, Emergency Room, or Hospital.

Coverage contextMedically necessary urgent care services at in‑network urgent care centers within the service area are covered; out‑of‑service‑area urgent care may be covered per limited out‑of‑network provisions.

ExamplesTypical urgent care conditions include minor injuries, acute illness symptoms, and other non‑emergent conditions where timely care is needed.

Telehealth Service

DefinitionTelehealth Service: a virtual visit with a qualified provider using audio‑video or audio‑only telecommunications; Telehealth may be used for covered services rendered by in‑network Providers.

ExclusionsTelephone‑only, text, email, EHR messaging, and remote patient monitoring are not considered Telehealth Visits and are excluded from Telehealth coverage where specified.

LimitationsExcluded or limited services remain excluded when delivered via Telehealth; CareSource may deny Telehealth visits that cannot reasonably be completed online (e.g., comprehensive physical exams).

Dependent / Eligible Person

DependentDependent generally refers to the Subscriber's spouse and children; an Enrolled Dependent is a Dependent who has been enrolled under the Policy.

Eligible PersonAn Eligible Person is someone who may enroll under the Policy and become a Covered Person when properly enrolled and residing within the Service Area.

Enrollment noteWhen an Eligible Person enrolls, CareSource treats that person as a Covered Person or member and eligibility rules in Section 2 apply.

CareSource responsibilities

Benefit determinationsCareSource makes administrative decisions about whether the Policy will reimburse for services, applying network status, authorizations, limitations, and exclusions to Claims.

Delegation and contractingCareSource may delegate administrative services (e.g., PBM) and contracts with Providers to form its network; credentialing confirms licensure but does not guarantee quality of care.

Provider network changesProvider network composition may change; members should contact Member Services to confirm In‑Network Provider availability.

You Are No Longer Eligible

Termination timingCoverage ends on the last day of the calendar month in which you are no longer eligible to be a Subscriber or Enrolled Dependent.

Dependent age ruleIf a Dependent reaches age 26 during a calendar year, eligibility ends on the last day of that calendar year (subject to exceptions for disabled dependents).

ReferenceSee Section 2 for full definitions of Eligible Person, Subscriber, Dependent, and Enrolled Dependent.

Coverage for a Disabled Dependent Child

Continuation for disabled childCoverage for an unmarried Enrolled Dependent child who is disabled will continue beyond the limiting age if the child depends mainly on the Subscriber for support and is not self‑supporting due to mental or physical handicap, provided medical certification is supplied.

Proof timelineCareSource may require proof of medical certification within 31 days of the date coverage would have ended and may require periodic proof thereafter (not more than once per year after the initial two‑year period).

Examination rightCareSource may require an examination by a Provider chosen by CareSource at CareSource's expense before extending coverage for the disabled dependent.

Balance Billing

DefinitionBalance Billing occurs when an Out‑of‑Network Provider bills the member for the difference between the Provider's billed amount and CareSource's Maximum Allowed Amount.

When may occurMembers may be balance billed for ground ambulance, urgent care, non‑emergency services, and referrals to Out‑of‑Network Providers lacking a negotiated rate.

ProtectionsMembers cannot be balance billed for Emergency services, covered ancillary services at In‑Network facilities, or Emergency Air Ambulance; In‑Network Providers cannot balance bill for Covered Health Services.

Continuity of Care

PCP continuityIf a Primary Care Provider who was in‑network at enrollment later leaves without cause, the member may continue accessing that PCP at In‑Network benefit levels through the end of the Policy year.

Non‑PCP continuityFor non‑PCP providers leaving the network after enrollment, members may continue at In‑Network benefit levels for up to 90 days, the end of the course of treatment, or the end of the Policy year, whichever is shorter.

Pregnancy exceptionPregnant members in their third trimester at initial enrollment may continue obstetric care with their Out‑of‑Network provider through postpartum care; first/second trimester enrollees must transition to an In‑Network provider.

Prior Authorization (definition)

DefinitionPrior Authorization (as defined in Section 2) is the pre‑service review and determination based on submitted clinical information to assess Medical Necessity for specified services.

List and contactServices requiring Prior Authorization are listed on the Prior Authorization list available via Member Services or the website; Providers are responsible for obtaining authorization on behalf of members.

ConsequencesFailure to obtain Prior Authorization when required may result in application of penalties or denial of Benefits; authorization is not a payment guarantee.

Experimental or Investigational

DefinitionExperimental, Investigational, or Unproven Services are services, technologies, supplies, drugs, devices, or procedures not recognized as standard of care for the requested use and are excluded from coverage.

Determination processCareSource determines Experimental/Investigational status using peer‑reviewed evidence, specialty society guidance, expert opinion, and review panels (including pharmacy & therapeutics for drugs).

Clinical trial noteParticipation in an approved clinical trial does not automatically make investigational items covered; routine patient care costs for qualifying in‑network trials may be covered per criteria.

Biofeedback

Definition and coverageBiofeedback is a method to learn voluntary control of body functions using a special machine; Covered when used for migraine, spastic torticollis, and urinary incontinence and provided by a physical therapist or certified mental health/substance abuse professional.

Provider requirementBiofeedback services should be provided by an appropriately licensed physical therapist or certified mental health/substance use professional to be Covered.

ExclusionsBiofeedback for temporomandibular disorder (TMD) is specifically excluded elsewhere in the policy.

Habilitative Services

DefinitionHabilitative Services are health care services that help a person keep, learn, or improve skills and functioning for daily living (e.g., PT, OT, ST) provided under a written treatment plan by licensed therapists.

Visit limitsPhysical, occupational, and speech therapy for habilitative purposes are limited to 20 visits each per year and must be evidence‑based and under a written treatment plan.

Not combined with rehabilitativeHabilitative services are not to be combined with Rehabilitative Services for benefit counting.

Skilled care

DefinitionSkilled care (home health) refers to skilled nursing, teaching, or skilled rehabilitation services that are not custodial and require licensed personnel to achieve a specified medical outcome.

Coverage criteriaHome health services are Covered when ordered by a Provider, provided by an in‑network licensed or Medicare‑certified Home Health Agency, would otherwise require hospital/SNF confinement, and are part‑time or intermittent skilled care.

LimitHome health benefits are limited to 60 visits per calendar year; up to four consecutive hours of skilled care equals one visit.

Palliative Care

DefinitionPalliative Care is supportive care focused on symptom management and quality of life for patients with chronic medical conditions; it is not curative and may be provided in home, clinic, or hospital settings.

Ordering and networkPalliative Care must be ordered by a Provider and delivered by an in‑network hospice‑certified Provider to receive benefits under the Policy.

Care teamPalliative care is interdisciplinary and focuses on early identification, assessment, and treatment of pain and related issues to improve quality of life.

Hospice Care eligibility

EligibilityHospice care is Covered when the attending Provider confirms a life expectancy of one year or less and care is provided by a licensed hospice agency as part of an approved plan.

Covered servicesCovered hospice services include interdisciplinary team care, skilled nursing, home health aide under supervision, short‑term inpatient/respite care, social work and counseling, PT/OT/ST, dietary support, and pharmaceuticals/equipment for palliation.

Certification requirementTo be eligible, the patient's life expectancy must be confirmed by the attending Provider; refer to Schedule of Benefits for payment details and limits.

Routine foot care — exception

Exception conditionsRoutine foot care exclusions do not apply for Covered Persons with systemic illnesses (e.g., diabetes, peripheral vascular disease, peripheral neuropathies) where neurovascular integrity may be compromised.

Covered examplesIn such circumstances, performing routine foot care by a clinician may be covered to prevent self‑injury or future complications such as ulcers, infection, or diminished protective sensation.

General exclusionAbsent those systemic conditions, routine foot care (e.g., nail trimming, hygienic care) is not covered.

Preventive services (no cost share) conditions

Coverage conditionsPreventive services covered at no cost share must be screenings (no symptoms), age‑appropriate, provided outpatient and In‑Network, and still subject to Medical Necessity and other policy provisions.

ExamplesCovered preventive services follow USPSTF A/B recommendations, ACIP immunization guidance, and HRSA‑supported guidelines for children and women as applicable.

Cost‑sharing noteThe Plan provides some preventive services without Deductible, Copayment, or Coinsurance when provided In‑Network; other preventive services may remain subject to cost‑sharing depending on category and plan specifics.

Telehealth Service details and exclusions

Covered TelehealthTelehealth visits rendered by in‑network Providers (audio‑video or audio‑only) may be Covered for appropriate services; Telehealth is not intended to replace Emergency Services.

Exclusions and non‑covered modalitiesTelephone‑only calls, text messages, email, patient portal/EHR messaging, and remote patient monitoring are excluded from Telehealth coverage in many cases and are not considered Telehealth Visits.

LimitationsAn excluded or limited service remains excluded or limited when delivered via Telehealth; CareSource may deny Telehealth visits that cannot reasonably be completed online (e.g., comprehensive physical exams).

Designated Facility/Center of Excellence

DefinitionDesignated Facility/Center of Excellence: Transplant services must be received at a Designated Facility using Designated Providers or Centers of Excellence as specified by CareSource to be Covered.

Authorization requirementCertain transplant services and related supplies require Prior Authorization by CareSource and must adhere to CareSource transplant guidelines.

Donor cost ruleDonor‑related charges for organ removal are Covered only if the transplant recipient is a Covered Person; benefits payable through the recipient's coverage.

Prior Authorization (PA)

PA (formulary)Prior Authorization (PA) on the Formulary requires providers to submit clinical information before the drug will be covered; PA entries display as 'PA' on the Formulary.

Submission and bypassProviders must submit clinical information electronically or by fax for PA, QL, ST, or AL bypass/exception requests; coverage for drugs outside limits is not provided until approval.

Appeals and external reviewDenied PA or non‑formulary exception requests may be appealed per the appeals process and may proceed to independent external review where applicable.

Quantity Limit (QL)

DefinitionQuantity Limit (QL) is a formulary restriction that limits how much of a drug may be dispensed at one time or over a specified timeframe.

PurposeQLs align use with FDA‑approved dosing, promote safety, and manage cost‑effective prescribing.

Bypass processProviders can request a bypass of a QL by submitting clinical justification electronically or by fax; coverage is contingent on approval.

Step Therapy (ST)

DefinitionStep Therapy (ST) is a formulary requirement that a member try specified lower‑cost or preferred alternatives before coverage of a higher‑tier drug is provided.

Bypass optionProviders may request a bypass of Step Therapy by submitting clinical information electronically or by fax; coverage of the step‑therapy drug requires approval.

Formulary displayST entries are shown as 'ST' on the Formulary to indicate the requirement and assist providers in prescribing.

Age Limit (AL)

DefinitionAge Limit (AL) is a formulary restriction that prevents coverage of a drug if the member is above or below a specified age, typically reflecting FDA approvals or dosage appropriateness.

Bypass processProviders can request coverage outside the Age Limit by submitting a bypass request with clinical justification; coverage is not provided until approved.

Formulary displayAL entries appear on the Formulary to inform providers and members of age‑based coverage restrictions.

Experimental or Investigational Services

DefinitionExperimental, Investigational, or Unproven Services are services, technologies, drugs, devices, or procedures not recognized as standard of care for the requested use and are excluded from coverage.

Review processCareSource uses peer‑reviewed literature, specialty society guidance, expert panels, and a pharmacy & therapeutics review for drug determinations to assess whether a service is Experimental/Investigational.

Clinical trial exceptionParticipation in qualifying in‑network clinical trials may result in coverage of routine patient care costs per criteria, but investigational items remain excluded unless specified.

Primary Plan

Primary PlanPrimary Plan is the plan required to pay first when a person is covered by two or more plans; it includes group and non‑group insurance, HMOs, closed panel plans, and certain government plans as permitted by law.

Allowable ExpenseAn Allowable Expense is a health care expense that is covered at least in part by any Primary Plan and the CareSource policy; expenses not covered by any plan are not Allowable Expenses.

Notification requirementMembers must notify CareSource if they have other coverage that constitutes a plan, so coordination of benefits rules can be applied.

Allowable Expense

DefinitionAllowable Expense: a health care expense (including Deductibles, Copayments, Coinsurance) that is Covered at least in part by any Primary Plan and the CareSource policy; certain items (amounts above highest negotiated fee, private room differentials) are not Allowable Expenses.

Examples excludedAmounts above the highest reimbursement or negotiated fee, private room differential (unless covered), and benefit reductions due to noncompliance with plan provisions are not Allowable Expenses.

Effect on COBAllowable Expenses are used to determine payment obligations when coordinating benefits with other plans; non‑Allowable Expenses are not considered in benefit calculations.

Closed Panel Plan

DefinitionClosed Panel Plan: a plan providing benefits primarily through contracted panel providers and excluding others except in emergencies or when an In‑Network referral and approval are provided.

Coordination implicationIf a member is enrolled in multiple Closed Panel Plans and one plan denies payment for non‑panel services, coordination of benefits between Closed Panel Plans may not apply.

ExamplesClosed Panel Plans include some HMOs or employer plans that restrict benefits to a contracted provider network.

Custodial Parent

DefinitionCustodial Parent: the parent awarded custody by court decree or, if none, the parent with whom the child resides more than half the calendar year (excluding temporary visitation).

COB relevanceCustodial parent rules affect order of benefit determination for dependent children when parents have separate plans.

DocumentationCareSource may require proof of custody arrangements to apply dependent coordination rules correctly.

Subrogation

DefinitionSubrogation is CareSource's right, upon paying Benefits, to step into the Covered Person's place to recover the reasonable value of services from third parties who are liable or obligated to pay.

Recovery scopeCareSource may seek reimbursement or recovery from third parties, other insurers, underinsured/uninsured motorist coverage, workers' compensation, or any person/entity liable for the Covered Person's injuries or expenses.

Member obligationIn consideration of coverage, the member must cooperate with subrogation and reimbursement efforts; CareSource has an independent right to be reimbursed for benefits it provides.

OpenPayer

Certificate of Coverage (CareSource EPO Policy)

Coverage Criteria and Limits

Coding, Billing and Code-level Guidance

Provider Responsibilities, Prior Authorization and Utilization Rules

Definitions and Term Clarifications