File a Complaint

We hope you will be happy with CareSource and the service we provide. If you are unhappy with anything about CareSource or its providers you should contact us as soon as possible. This includes if you do not agree with a decision we have made. You, or someone you want to speak for you can contact us. If you want someone to speak for you, you will need to let us know this. CareSource wants you to contact us so that we can help you. To contact us, you can:

  • Fill out the form in your Member Handbook; or
  • Write a letter telling us what you are unhappy about. Be sure to put your first and last name, the number from the front of your CareSource member ID card, and your address and telephone number in the letter so that we can contact you, if needed. You should also send any information that helps explain your problem; or
  • Call Member Services at 1-800-488-0134 (TTY: 1-800-750-0750 or 711).

Mail the form or your letter to:

CareSource
Attn: Grievance Department
PO Box 1947
Dayton, OH 45401-1947

CareSource will send you something in writing if we make a decision to:

  • Deny a request to cover a service for you;
  • Reduce, suspend or stop care you are already receiving; or
  • Deny payment for a service you received that is not covered by CareSource.

We will also send you something in writing if, by the date we should have, we did not:

  • Make a decision on whether to okay a request to cover a service for you; or
  • Give you an answer to something you told us you were unhappy about.

If you do not agree with the decision/action listed in the letter, and you contact us within 90 calendar days to ask that we change our decision/action, this is called an appeal. Unless we tell you a different date, we will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us. You can also appeal by phone or in writing. You can submit information to help explain your case if you want.

If you contact us because you are unhappy with something about CareSource or one of our providers, this is called a grievance. CareSource will give you an answer to your grievance by phone (or by mail if we can't reach you by phone) within the following time frames:

  • 2 working days for grievances about not being able to get medical care
  • 30 calendar days for all other grievances except grievances that are about getting a bill for care you have received
  • 60 calendar days for grievances about getting a bill for care you have received

If you are not happy with our answer to your grievance, you can ask us to reconsider it. To do so, you must call or send a letter to CareSource within 15 working days of getting our answer/decision about your grievance. A meeting will be held within 10 working days from the date CareSource gets your request. You, and/or someone you have chosen to represent you, can be at the meeting and present information. CareSource will send you an answer by certified mail within three working days of the meeting.

You also have the right at anytime to file a complaint by contacting the:

Ohio Department of Job and Family Services
Bureau of Managed Health Care
P.O. Box 182709
Columbus, Ohio 43218-2709
1-800-605-3040 or 1-800-324-8680
(TTY: 1-800-292-3572)
Ohio Department of Insurance
2100 Stella Court
Columbus, Ohio 43215
1-800-686-1526
 

State hearings

If CareSource has made a decision to deny, reduce, suspend, or stop care for you, or if a provider is billing you because our plan is denying payment to them, you have the right to ask for a state hearing. At the time CareSource makes the decision, or is aware that the provider is billing you for payment, we will mail you a form. If you want a state hearing, you must sign and return the form to the address listed on the form within 90 calendar days from the mailing date on the form or you can also call the Bureau of State Hearings at 1-866-635-3748. A state hearing is a meeting with you, someone from the County Department of Job and Family Services, someone from CareSource and a hearing officer from ODJFS. CareSource will explain why we made our decision and you will tell why you think we made the wrong decision. The hearing officer will listen and then decide who is right based upon the information given and whether we followed the rules. If you want information on free legal services but don't know the number of your local legal aid office, you can call the Ohio State Legal Services Association at 1-800-589-5888, for the local number.

External review

In addition to a state hearing, you may ask for an independent review if CareSource decides not to approve medical care that has been requested for you. This is done by a certified medical review company. It is not done by CareSource. You must go through CareSource's appeal process first and ask for one within 45 days of getting our answer to your appeal.

To ask for one, please write to us at:

CareSource
Attn: Independent Review - QI Dept.
P.O. Box 8738
Dayton, OH 45401-8738

Or you can call Member Services to request it. Just call 1-800-488-0134 (TTY: 1-800-750-0750). Your case may be urgent. If so, you will get an answer within 72 hours of asking for the review. If it is not urgent, you will get an answer in 30 days