Medicare AdvantageDocumentationHigh impact
[Ohio] Prepay Auditing Update
CareSource·OH·Provider Bulletin
Effective date
Mar 2, 2026
We identified it
May 9, 2026
Summary
CareSource is implementing enhanced prepay claims auditing effective March 2, 2026, requiring providers to submit medical records for claims flagged with reason codes BB1 or PJR. Claims will not be paid until medical records are received and reviewed for compliance with CMS, AMA, and AHA coding guidelines; records must be submitted within 365 days or claims remain denied.
Action Required
By March 2, 2026: Billing team must establish workflow to monitor CareSource EOPs for reason codes BB1 or PJR indicating prepay claim review flags. Train billing staff to immediately submit requested medical records through CareSource Provider Portal using Submission Reason 'Pre Pay Claim Review – Notes Required.' Establish internal tracking system to ensure medical records are submitted within 365 days of claim receipt to prevent claim denials. Review and update documentation templates for all service types (Behavioral Health, Skilled Therapy, DME, Lab & Imaging, Medical E&M) to ensure they include all required elements per the policy attachment (treatment plans, signed orders, consent forms, progress notes, diagnostic reports, operative reports where applicable, and proof of delivery for DME). Communicate with all clinical providers that claims may be denied even after medical records submission if documentation does not support billed codes—submission is not a guarantee of payment. Implement escalation protocol for claims in denied status; monitor for appeals/dispute rights under CareSource Provider Manual.