CareSource Georgia Co. claim denials in Georgia: the federal figures
CareSource Georgia Co. denied 21.8% of in-network claims in Georgia — 361,615 claims out of 1,661,639. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to CareSource Georgia Co.) | 29 | 48.3% |
| External review (independent) | — | — |
What CareSource Georgia Co. denies most
The most common denial reason recorded for CareSource Georgia Co. plans in Georgia is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 227,481 | 41.6% |
| Provider out of network | 145,837 | 26.7% |
| Service excluded from the plan | 70,334 | 12.9% |
| Referral required | 52,349 | 9.6% |
| Member not covered | 23,525 | 4.3% |
| Benefit limit reached | 14,390 | 2.6% |
| Administrative reason | 12,780 | 2.3% |
What to do if CareSource Georgia Co. denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. CareSource Georgia Co. overturned 48.3% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not CareSource Georgia Co.. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your CareSource Georgia Co. appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is CareSource Georgia Co.'s denial rate high?
21.8% against a national average of 16% across the plans in this dataset. It is above average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can CareSource Georgia Co. ignore the external decision?
No. External review decisions are binding on the plan.