Appeals

An appeal is how you ask us to review our actions. You might get a letter of denial telling you that a service is ending. If you do not agree with the denial, you can ask for an appeal. You must ask for an appeal within 60 days from the notice date. You, your parent or legal guardian, or someone you choose to speak for you with your written consent can file an appeal with CareSource PASSE.

An appeal can be filed in one of these ways:

  • Calling Member Services at 1-833-230-2005 (TDD/TTY: 711) and telling us, or we can mail you a paper form.
  • Filling out the NavigateGrievances and Appeals form.
  • Mailing a letter to:
    CareSource PASSE
    Attn: Member Appeals
    P.O. Box 1947
    Dayton, OH 45401-1947

After we get your appeal, we will send you a letter within 5 days to let you know we received it. The people making appeal decisions are not involved in earlier reviews. They are health care professionals supervised by the CareSource PASSE medical director. They have clinical expertise of your health problem or disease. They can decide:

  1. An appeal of a denial that is based on lack of medical necessity.
  2. An appeal that involves clinical issues.

You or someone acting for you can send us more information to consider as part of your appeal. If your appeal is urgent, tell us as soon as possible but no later than 60 calendar days from the date of the denial. You can also review your case file and health records. You can review any other appeal process papers free of charge.

Appeal Decision

We will tell you and your provider of the appeal decision. We will send written notice to you and others acting for you with your written consent.

You may ask for a State Fair Hearing if you do not agree with our appeal decision. Before you can ask for a State Fair Hearing, an internal appeal must be done. If we do not follow the notice and timing rules in this handbook, then you may ask for a State Fair Hearing before our internal appeal process is done.

Member Services: 1-833-230-2005 (TDD/TTY: 711) Monday through Friday, 8 a.m. – 5 p.m. CT