CurrentCareSourcePolicy N/A

Provider Prepayment Review - Arkansas PASSE

Governs CareSource's provider prepayment review program for Arkansas PASSE to detect, prevent, and correct fraud, waste, and abuse and to ensure accurate claim payments; affects participating providers whose claims may be selected for prepayment review.

Policy Summary

PayerCareSource

PolicyProvider Prepayment Review - Arkansas PASSE

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders placed on prepayment review must submit medical records for all identified claims and upload them to the CareSource Provider Portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 dayswritten notice timeframe

3months for release eligibility

12 monthsmaximum review duration

6 monthsno billing activity threshold

Prepayment Review Coverage Criteria

Claims selected for prepayment review are evaluated for payment appropriateness using submitted documentation and established guidelines; payment is allowed only when documentation and policy requirements are met.

Providers placed on prepayment review must submit medical records for all identified claims and upload records to the CareSource Provider Portal; claims selected for prepayment review will be soft denied and do not require an appeal to resolve.

Failure to submit required medical records or to meet minimal documentation standards (e.g., member name and date of service on each page, signed dated order, valid provider signature) will result in claim denial or the claim remaining denied.

Reviews use nationally recognized sources and CareSource policies (including CMS manuals, Medicare coverage determinations, CareSource published policies, AMA CPT/HCPCS, ICD-10-CM guidelines, MCG, FDA guidance, and professional society guidelines) to determine payment appropriateness and medical necessity.

Payment requires documentation that establishes services were provided according to CareSource policy requirements and were medically necessary.

Policy Summary

PayerCareSource

PolicyProvider Prepayment Review - Arkansas PASSE

Policy CodePolicy N/A

Change TypeAdministrative (no material coverage changes)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders placed on prepayment review must submit medical records for all identified claims and upload them to the CareSource Provider Portal.

SourceLink

On This Page

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Submission, Soft Denials, Release, and Escalation Actions

Documentation Required

Submission and Soft Denial Process

Providers placed on prepayment review must submit medical records for all identified claims and upload them to the CareSource Provider Portal. Claims selected for prepayment review will be soft denied; a soft denial does not require an appeal but does require record submission. Failure to submit records or to meet minimal documentation standards (for example: member name and date of service on each page, a signed dated order, and a valid provider signature) will result in the claim remaining denied.

Submit medical records for all identified claims when placed on prepayment review.
Upload all requested records to the CareSource Provider Portal.
Soft-denied claims do not require an appeal but must have records uploaded to resolve the denial.
Failure to submit records or meet minimal documentation standards will result in claim denial.

Denial Risk

Release and Escalation Actions

A provider may be released from prepayment review after demonstrating a high claim accuracy rate for 3 consecutive months, maintaining consistent claim volume, and returning a high rate of records after soft denial. If the provider fails to meet these requirements, CareSource may escalate up to 12 months on review with actions including outreach/education, requiring a corrective action plan, denying payment for services during a specified period, or terminating the provider agreement (including termination for 6 months of no billing activity).

Release eligibility: high accuracy for 3 consecutive months, consistent claim volume, and high rate of records returned after soft denial.
After up to 12 months of noncompliance, actions may include outreach/education, corrective action plan, denial of payment for a period, or termination of the provider agreement.
Termination conditions include no billing activity for 6 months or claim submission volume not consistent with pre-review volume.

Key Definitions

Provider Prepayment Review

DefinitionProvider Prepayment Review: reviews of medical record documentation and comparison to billed services to determine whether claims are appropriate for payment prior to adjudication.

Team compositionConducted by the Program Integrity Provider Prepayment Review Team composed of clinical review and coding specialists (CPC, RHIA, RHIT).

Primary focusEvaluation includes verification that services were provided according to CareSource policy requirements, member eligibility, prior authorization, and provider qualifications.

Soft Denial

DefinitionSoft Denial: a denial applied to claims selected as part of the prepayment review audit; soft denials do not require an appeal to resolve and are identified by RARC code 127 on the remittance advice.

Operational actionProviders must upload medical records to the CareSource Provider Portal for the denied claim to resolve the soft denial.

Appeal requirementSoft denials do not require an appeal; providers may dispute or appeal other audit determinations per timely filing limits as outlined in the provider manual.

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 taxpayer funds appropriately with minimal waste.

Program rolePI operates the provider prepayment review program to detect, prevent, and correct fraud, waste, and abuse and to facilitate accurate claim payments.

Provider recourseProviders may dispute or appeal claim denials resulting from PI reviews within timely filing limits as outlined in the provider manual.

OpenPayer

Provider Prepayment Review - Arkansas PASSE

Prepayment Review Coverage Criteria

Codes, Accuracy Periods, and Coding Review

Submission, Soft Denials, Release, and Escalation Actions

Key Definitions

CPT/HCPCS	Review includes verification of correct CPT/HCPCS selection and detection of upcoding or wrong code selection.
ICD-10	ICD-10-CM official guidelines used for coding and reporting.