CurrentCareSourcePolicy Program Integrity Provider Prepayment Review-AR PASSE-AD PASSE-AD-1096

Program Integrity Provider Prepayment Review-AR PASSE-AD-1096

Defines CareSource's program integrity prepayment review process for providers in the Arkansas PASSE program, including reasons for placement on prepayment review, provider obligations (medical record submission via portal), review sources, appeal/dispute rights, and release criteria.

Policy Summary

PayerCareSource

PolicyProgram Integrity Provider Prepayment Review-AR PASSE-AD-1096

Policy CodePolicy Program Integrity Provider Prepayment Review-AR PASSE-AD PASSE-AD-1096

Change TypeEditorial additions and clarifications

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen placed on prepayment review providers must upload medical records for all identified claims to the CareSource Provider Portal.

SourceLink

POLICY UPDATE CHANGES

Added written notice guidelines in section II.

Added definition for Soft Denial.

Replaced 30 day requirements and substituted language to require 'all identified claims'.

30 daysWritten notice timeframe

12 monthsMaximum review period

3 monthsMonths of high accuracy for release

RARC 127Remittance advice code for soft denials

Prepayment Review Criteria

Prepayment review criteria

Claims selected for prepayment review are evaluated for appropriateness of payment by comparing submitted medical record documentation to billed services and by applying applicable policies and nationally recognized guidance.

Provider was benefit eligible on date of service

Based on Program Integrity review criteria.

Services were provided according to CareSource policy requirements and nationally recognized guidelines (CMS, Medicare LCD/NCD, CPT, HCPCS, ICD-10-CM, AMA, FDA, MCG, specialty society publications, and other evidence-based literature)

Prior authorization was obtained, if required by policy

Provider possessed required license/certification and staff met applicable state or federal qualification requirements at time of service

Policy Summary

PayerCareSource

PolicyProgram Integrity Provider Prepayment Review-AR PASSE-AD-1096

Policy CodePolicy Program Integrity Provider Prepayment Review-AR PASSE-AD PASSE-AD-1096

Change TypeEditorial additions and clarifications

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen placed on prepayment review providers must upload medical records for all identified claims to the CareSource Provider Portal.

SourceLink

On This Page

Coding-related Review Details

Coding-related reasons for reviewmixed

selection of wrong CPT/HCPCS	Mis-selection of procedure or supply codes may trigger prepayment review
upcoding	Billing codes that inappropriately increase reimbursement may trigger review

inv-03: accuracy for release

Release requirementProvider must demonstrate a high accuracy rate on claim submissions for 3 consecutive months to be eligible for release from prepayment review

Monthly monitoringCareSource reviews provider accuracy monthly to determine ongoing eligibility for release

Consistent claim volumeProvider claim volume must remain consistent with volume before prepayment review

Records returned after soft denialProvider must maintain a high rate of records returned after soft denial

inv-04: maximum review duration before escalations

Maximum documented review periodCareSource may take escalated actions if provider fails to meet release requirements after 12 months on prepayment review

Potential escalationsActions after 12 months may include requiring a corrective action plan, outreach/education, denial of payment for services during a specified period, or termination of the provider agreement under certain conditions

Termination conditionsTermination may be considered if no billing activity for 6 months or if claim submission volume during review is not consistent with pre-review volume

Provider Obligations and Rights

Documentation Required

Upload medical records for all identified claims; soft denials handled by portal upload

When placed on prepayment review, providers must upload medical records for all identified claims through the CareSource Provider Portal. Claims selected for prepayment review will be soft denied; soft denials do not require an appeal — upload the requested records to resolve. Failure to submit medical records in accordance with these requirements will result in the claim remaining denied.

Upload medical records for all identified claims via the CareSource Provider Portal.
Soft denials are identified on the remittance advice by RARC code 127 and do not require an appeal.
If records are not submitted as required, the claim will remain denied.

Prior Authorization

Written notice within 30 days (or per federal/state) — immediate review allowed in certain circumstances

CareSource will provide written notice of placement on prepayment review within 30 days or within the applicable federal/state guideline. In certain circumstances (for example, state-directed reviews or suspected fraud) CareSource may implement prepayment review immediately and notify the provider after the action.

Written notice within 30 days or per federal/state guidelines.
Immediate implementation allowed in cases such as state-directed reviews or suspected fraud, with subsequent provider notification.

Denial Risk

Provider dispute and appeal rights — follow provider manual and contact Program Integrity

Providers may dispute or appeal determinations in accordance with timely filing limits and processes described in the provider manual; contact the Program Integrity prepayment review team for questions or to initiate a dispute or appeal.

Dispute/appeal rights follow timely filing limits and provider manual procedures.
Contact Program Integrity prepayment review team for assistance.

Key Definitions

inv-08: Soft Denial

DefinitionSoft Denial: A denial applied to claims selected as part of the prepayment review audit; does not require an appeal to resolve; upload records to the CareSource Provider Portal for the denied claim

Remittance advice codeSoft denials are identified in the remittance advice by RARC code 127 'Missing patient medical record for this service'

Operational noteProviders should upload medical records for soft-denied claims via the CareSource Provider Portal to resolve the denial—no formal appeal required

inv-09: Provider Prepayment Review

DefinitionProvider Prepayment Review: Reviews of medical record documentation and comparison to billed services conducted prior to claim adjudication

PurposeTo determine whether claims are appropriate for payment based on documentation and criteria such as member eligibility, policy compliance, prior authorization, provider qualifications, and documentation minimums

Team compositionProgram Integrity Provider Prepayment Review Team includes clinical review and coding specialists holding CPC, RHIA, or RHIT designations

inv-10: Program Integrity (PI)

DefinitionProgram Integrity (PI): The proper management and functioning of a health insurance program to ensure it provides quality and efficient care while using funds appropriately and minimizing waste

RolePI operates a provider prepayment review program to detect improper billing and ensure appropriate payment practices

GoalsEnsure quality care, efficient use of funds, and minimize waste through review and enforcement actions when necessary