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  • Caresource Appeal And Claim Dispute Form

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Appeal and Claim Dispute Form Phone: 18662869949CLAIM TYPE: UB04 HCFA1500 ADAPATIENT INFORMATION DATE OF SERVICE: CLAIM #: NAME: CARESOURCE ID NUMBER: PROVIDER INFORMATION PROVIDER NPI: PROVIDER TAX.

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Administrative Appeals You can send a requests for an administrative appeal in writing to the BSH at the same address, within 15 calendar days of the date the hearing decision was issued. The adult receiving services, the authorized representative, the legal guardian, or the parent of a minor child can submit requests.

Appeals must be submitted within 365 calendar days of date of service or date of discharge.

Call us, toll free at the following number: 1-866-635-3748, and choose option number one from the automated voice menu. If your assistance is continuing and you lose the hearing, you may have to pay back any benefits that you were not eligible to receive.

Call Member Services at 1-855-475-3163 (TTY: 1-800750-0750 or 711), Monday – Friday, 8 a.m. – 8 p.m. Fill out the Member Grievance/Appeal Form.

Provider claim disputes must be received at CareSource no later than 12 months (365 calendar days) from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later (i.e. claim recovery/recoupments).

Clinical Appeals If you disagree with a clinical decision we have made regarding medical necessity, we make it easy for you to be heard. After receiving a letter from Humana – CareSource® denying coverage, the provider or the member can submit a clinical appeal within 60 calendar days of receipt.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232