Centene operates Medicaid managed care through subsidiaries including WellCare, Ambetter, Peach State, Sunshine Health, and others. Appeal deadlines follow state Medicaid rules, typically 30-60 days from denial notice. Each state plan has its own appeals address and process.
Day 1: Receive denial. Days 1-10: Gather documentation. Day 11: Submit appeal. Days 12-42: State-specific review period (typically 30 days). If denied: request a state fair hearing within 120 days. Expedited appeals: 72-hour decision for urgent medical situations.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | Auth not obtained | Check state-specific PA requirements |
| CO-11 | Medical necessity | Clinical review denial | Include detailed clinical notes |
| CO-50 | Non-covered service | Service not in Medicaid benefit | Verify Medicaid coverage in member's state |
First-level appeal: submit within 30-60 days (state-specific). Centene responds within 30-45 days. If denied, request a state Medicaid fair hearing within 120 days of the original denial. Fair hearings are conducted by an administrative law judge and the decision is binding.
Check the member's ID card. Common Centene brands: WellCare (multiple states), Ambetter (marketplace), Peach State (Georgia), Sunshine Health (Florida), Home State Health (Missouri). Each brand has its own appeals address.
It depends on the state. Most states require appeals within 30-60 days of the denial notice. Check your state's Medicaid provider manual or the denial letter for the exact deadline.
Yes. After exhausting Centene's internal appeal, you or the member can request a state Medicaid fair hearing. Filing deadlines vary by state but are typically 120 days from the denial or 90 days from the appeal decision.
Altair identifies which Centene subsidiary covers each member and tracks state-specific appeal deadlines.