CareSource Billing Guide for Behavioral

CareSource

CareSource Medicaid MCO provider guide for behavioral health — credentialing, VOB, prior authorization, billing across its multi-state footprint.

Quick Reference

Payer Type

Medicaid MCO

Parent Company

(independent not-for-profit health plan)

Headquarters

Dayton, OH

Provider Portal

Open Portal

Portal Guide

View Guide →

Credentialing

CAQH ProView plus state Medicaid enrollment

Timeline

60-120 days

Coverage

8 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

9 min

Covered Levels of Care

• Medically Managed Detoxification
• Residential Treatment (state-dependent via 1115 SUD waivers)
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient Treatment
• Crisis Stabilization and Mobile Crisis
• Medication-Assisted Treatment (MAT)
• Peer Support and Recovery Services

Medical Necessity Criteria

• State-Specific Medicaid Guidelines
• ASAM Criteria (for SUD level of care determinations)
• State-adopted mental health criteria (LOCUS, CALOCUS, or equivalent)

Streamline payer billing?

Overview

CareSource is an independent not-for-profit health plan headquartered in Dayton, Ohio, and one of the largest Medicaid managed care organizations in the Midwest and Appalachian region. Founded in 1989 by Pamela Morris, CareSource began as an Ohio-only Medicaid plan and has grown into a multi-state organization serving Medicaid, Medicare Advantage (including D-SNP), and ACA marketplace members. As a nonprofit, CareSource reinvests surplus into operations, member programs, and the CareSource Foundation, which funds grants to community organizations across its service areas.

CareSource operates Medicaid managed care plans in Ohio, Kentucky, Indiana, Georgia, West Virginia, Michigan, North Carolina, and Arkansas (through the CareSource PASSE joint venture serving Arkansas Medicaid members with complex behavioral health needs). The plan is the largest Medicaid MCO in Ohio by enrollment and has a significant presence in Kentucky and Indiana. Medicare Dual Advantage and MyCare Ohio D-SNP products are offered in selected markets for members eligible for both Medicaid and Medicare.

For behavioral health treatment providers, CareSource is especially significant because its core footprint sits squarely in opioid-crisis states. The Ohio Department of Medicaid, Kentucky Department for Medicaid Services, Indiana Office of Medicaid Policy and Planning, and West Virginia Bureau for Medical Services have all directed substantial State Opioid Response (SOR) and SUPPORT Act funding through their managed care programs, and CareSource is a primary conduit for that spending. Providers contracting with CareSource should be fluent in state-specific Medicaid rules, EPSDT coverage for members under 21, and Section 1115 SUD waiver provisions.

Behavioral Health Coverage

CareSource covers behavioral health services as defined by each state’s Medicaid program. Commonly covered services across state plans include outpatient individual, group, and family therapy; psychiatric evaluation and medication management; intensive outpatient programs (IOP); partial hospitalization programs (PHP); crisis stabilization and mobile crisis; medication-assisted treatment for opioid and alcohol use disorders; and peer support services. Most CareSource state plans also cover assertive community treatment (ACT), targeted case management, and psychosocial rehabilitation for members with serious mental illness.

Residential SUD treatment coverage depends on the state’s Section 1115 SUD demonstration waiver. Ohio, Kentucky, West Virginia, and Indiana all operate with approved SUD waivers that allow Medicaid payment for short-term residential stays — generally up to 30 days per episode — in qualifying IMD facilities. The SUPPORT for Patients and Communities Act of 2018 further codified state flexibility to cover MAT and certain institutional SUD services. Confirm your state’s waiver status, facility size limits, and length-of-stay rules in the current state-specific provider manual before admitting CareSource members to a residential program.

For members under age 21, CareSource covers behavioral health services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT requires state Medicaid programs and their MCOs to cover any medically necessary service to correct or ameliorate a physical or mental condition, even if that service is not otherwise in the state plan. In practice, this means residential, wraparound, intensive community-based, and high-intensity home-based services for adolescents are covered when clinically justified, and medical necessity reviews must apply the broader EPSDT standard rather than adult benefit limits.

Medical necessity for SUD services is evaluated using the ASAM Criteria in every CareSource state, and mental health services are evaluated using each state’s adopted criteria — Ohio uses Ohio DBH and ODM source materials, with legacy OhioMHAS naming still appearing in some references, Kentucky uses a combination of ASAM and state criteria, and Georgia uses its Medicaid Behavioral Health guidelines. Clinical documentation should align explicitly with the criteria adopted in your state.

Credentialing and Provider Enrollment

CareSource uses CAQH ProView as its primary credentialing data source. Before applying, ensure every individual clinician and your facility have fully attested CAQH profiles with current licensure, NPI and taxonomy information, malpractice coverage, accreditation certificates, and service-location details.

State Medicaid enrollment is almost always a prerequisite. In Ohio, enroll through the Ohio Department of Medicaid Provider Network Management (PNM) module; in Kentucky, through the Kentucky Medicaid Partner Portal Application (KY MPPA); in Indiana, through IHCP Provider Enrollment; in Georgia, through the GAMMIS Provider Enrollment Portal; in West Virginia, through the WV Medicaid Provider Enrollment portal. Begin state Medicaid enrollment early — it is often the longest single step in the onboarding timeline. CareSource credentialing typically takes 60 to 120 days from receipt of a complete application, and claims will not pay until state Medicaid enrollment is also complete.

Facility-level credentialing requires current state behavioral health facility licensure, accreditation from Joint Commission, CARF, COA, or a state-recognized body, an organizational NPI, general and professional liability coverage at contracted limits, and a current W-9. CareSource may require a site visit for residential and crisis facilities. Recredentialing occurs on a standard three-year cycle, and lapses can result in claims being held or denied.

Verification of Benefits (VOB)

Verifying eligibility for CareSource members is a two-step process that differs from commercial payer workflows. First, confirm active Medicaid enrollment and MCO assignment through the state Medicaid eligibility portal — the Ohio Department of Medicaid MITS system, Kentucky’s KYHealthNet, Indiana’s CoreMMIS, Georgia’s GAMMIS provider web portal, West Virginia’s Medicaid provider portal, or the equivalent in each state. If the state portal shows the member is not enrolled on the date of service or is assigned to a different MCO, CareSource will not pay regardless of what its own portal shows.

Second, verify plan-specific behavioral health benefits through the CareSource provider portal at providerportal.caresource.com. The portal supports eligibility inquiries, benefits detail, authorization lookup, claim status, and electronic submissions. For complex behavioral health VOB — particularly facility-based services or members with coordination-of-benefits considerations — contact the state-specific provider services line listed on the member’s insurance card or in the current state provider manual.

Medicaid eligibility can change monthly based on redetermination, income changes, or coverage transitions. Re-verify eligibility on or near every date of service. Because Medicaid is the payer of last resort, screen for commercial, Medicare, TRICARE, or VA coverage that would take primary position. Document each VOB with date, representative name, reference number, and the specific benefits and authorization requirements confirmed.

Prior Authorization Requirements

CareSource generally requires prior authorization for residential SUD treatment (where covered), medically managed detoxification, inpatient psychiatric hospitalization, and partial hospitalization. IOP authorization requirements vary by state — Ohio and Kentucky commonly require PA for IOP while some other state plans do not. Outpatient therapy and office-based MAT with buprenorphine or naltrexone typically do not require PA, though a few state plans impose visit thresholds after which authorization becomes necessary.

Authorization requests are submitted through providerportal.caresource.com, by fax, or by phone to the state-specific utilization management team. The preferred channel is published in each state provider manual. Clinical documentation should cover diagnosis, presenting symptoms, substance use or psychiatric history, prior treatment episodes, current risk assessment, and the proposed treatment plan. For SUD requests, structure the narrative around the six ASAM Criteria dimensions and state the specific level of care requested; for mental health, document against the state’s adopted criteria.

Concurrent reviews for residential and inpatient levels of care are typically required every 3 to 7 days depending on the state and level of care; PHP reviews usually occur every 7 to 14 days. Each review requires updated clinical documentation showing progress, continued medical necessity, and active discharge planning. If a continued-stay request is denied, request a peer-to-peer review with the CareSource medical director before filing a formal appeal — many denials are resolved through peer-to-peer discussion.

Claims and Billing

CareSource accepts electronic claims through EDI 837I (institutional, UB-04) and 837P (professional, CMS-1500) submitted via clearinghouses, and through direct submission on providerportal.caresource.com. Electronic submission is strongly preferred. Confirm the correct payer ID for each state plan with your clearinghouse — CareSource uses different payer IDs across its Ohio Medicaid, Kentucky Medicaid, Indiana Medicaid, Georgia Families, and Medicare Advantage lines of business.

Billing codes, modifiers, and reimbursement rates follow each state’s Medicaid fee schedule and the CareSource provider contract. Use state-specific codes including SUD H-codes, EPSDT modifiers for members under 21, and any required place-of-service or taxonomy detail. State provider manuals publish current fee schedules and coding guidance — review them before submitting high-dollar facility claims or unfamiliar service codes.

Timely filing windows are set by each state Medicaid contract, not by CareSource corporate policy. Ohio’s MCO contract generally allows 365 days for initial claims; Kentucky, Indiana, Georgia, and West Virginia commonly use windows between 180 and 365 days. Corrected claims and coordination-of-benefits submissions usually have their own shorter windows. Late Medicaid claims have limited appeal rights, so the controlling deadline in the current state provider manual should be built into every revenue cycle workflow.

Common denial reasons include absence of required prior authorization, member not enrolled or assigned to a different MCO on the date of service, incorrect diagnosis codes, non-covered services, duplicate claims, and third-party liability issues. Track denial reason codes to identify systemic issues. File corrected claims for billing errors and formal appeals for clinical denials within the deadlines specified in the state provider manual.

Key Contact Information

State plans include: CareSource Ohio Medicaid, CareSource Kentucky Medicaid, CareSource Indiana Medicaid (Hoosier Healthwise, Healthy Indiana Plan), CareSource Georgia (Georgia Families, Pathways), CareSource West Virginia Medicaid, CareSource Michigan (MI Coordinated Health D-SNP), CareSource North Carolina, and CareSource PASSE (Arkansas).

• Provider Portal: https://providerportal.caresource.com ↗ (primary provider transaction platform for all CareSource plans)
• Credentialing: CAQH ProView ( https://proview.caqh.org ↗ ) plus state Medicaid enrollment; contact CareSource provider services in your state to initiate
• Prior Authorization: Submit through providerportal.caresource.com, fax, or the state-specific UM phone line listed in the current provider manual
• Verification of Benefits: Two-step — state Medicaid portal (Ohio MITS, KYHealthNet, CoreMMIS, GAMMIS, etc.) plus providerportal.caresource.com; for detail, call the state provider services line on the member’s ID card
• Claims Submission: Electronic 837I / 837P via clearinghouse (state-specific payer IDs) or providerportal.caresource.com
• State-Specific Provider Manuals: Available through the “Providers” section on caresource.com for each state line of business

Frequently Asked Questions

CareSource is a single not-for-profit parent organization headquartered in Dayton, Ohio, but each state line of business operates under a separate state Medicaid contract with its own provider manual, authorization requirements, and reimbursement methodology. A provider experience in Ohio, where CareSource is the largest Medicaid managed care plan, will differ in important ways from Georgia (Georgia Families and Pathways) or Michigan (the MI Coordinated Health D-SNP). Always reference the state-specific provider manual — available through providerportal.caresource.com — and treat each state contract as a distinct payer relationship even though the CareSource brand is consistent.

Residential SUD coverage follows each state's Section 1115 SUD waiver and Medicaid benefit design. Ohio, Kentucky, West Virginia, and Indiana have all operated 1115 SUD demonstrations that permit Medicaid payment for short-term residential stays in IMD facilities with more than 16 beds, typically capped at around 30 days per episode. CareSource funds residential levels of care in those states subject to ASAM Criteria and any state-specific length-of-stay or continued-stay rules. In states without an active waiver or for facilities that exceed the size threshold, Medicaid payment for residential treatment may be restricted to lower levels of care. Confirm waiver status and facility eligibility in the current state provider manual before admission.

The SUPPORT for Patients and Communities Act of 2018 requires state Medicaid programs and their MCOs to cover all FDA-approved medications for opioid use disorder — buprenorphine, methadone, and naltrexone — along with related counseling and behavioral therapies. CareSource generally covers office-based buprenorphine and oral naltrexone without prior authorization to reduce barriers to care, while long-acting injectables, opioid treatment program (OTP) encounters, and certain office-based methadone arrangements may require PA. CareSource is particularly active in MAT coverage across opioid-crisis states including Ohio, Kentucky, West Virginia, and Indiana, where state Medicaid programs have directed significant State Opioid Response (SOR) funding through managed care.

Eligibility verification is a two-step process. First, confirm active Medicaid enrollment and MCO assignment through the state Medicaid portal — the Ohio Department of Medicaid MITS system, Kentucky Medicaid's KYHealthNet, Indiana's CoreMMIS, Georgia's GAMMIS, or the equivalent in other states. If the state portal shows the member is not active or is assigned to a different MCO on the date of service, CareSource will not pay the claim. Second, verify plan-specific benefits, covered services, and authorization requirements on providerportal.caresource.com. Re-verify on or near every date of service — Medicaid eligibility can change monthly.

Timely filing limits are set by each state Medicaid contract. In Ohio, initial claims to CareSource generally must be filed within 365 days of the date of service under Ohio Department of Medicaid MCO contract rules; Kentucky, Indiana, Georgia, and West Virginia commonly use windows between 180 and 365 days. Corrected claims and coordination-of-benefits submissions usually have a shorter, separate window measured from the primary payer's determination date. The controlling deadline is always stated in the current state-specific provider manual — do not rely on general rules of thumb. Late Medicaid claims have limited appeal rights, so build timely filing alerts into your revenue cycle workflow from day one.

Related Payers

Key Billing Concepts

Revenue Cycle Resources

This guide is provided for informational purposes only and does not constitute legal, regulatory, or professional advice. Payer requirements, phone numbers, and portal URLs are subject to change. Always verify current information directly with the payer. is not affiliated with the insurance companies described on this page.

• Provider Portal
• Billing Hub
• Code Directory
• RCM Software

Common questions

Official sources

No publisher link is recorded for this topic yet. Confirm the requirement with the governing payer, state agency or accreditor before relying on it — see the primary source directory.