How and When to File an Appeal

What is an Appeal?

An appeal is not the same as a complaint or grievance. If you do not agree with a decision or action made by CareSource regarding your medical care, you have the right to appeal. An appeal is a request to reconsider and change the decision made or the action taken.

You have the right to appeal when:

  • CareSource denies a service.
  • CareSource gives partial approval to cover a service.
  • CareSource denies payment of a service.  

Internal Appeal of Adverse Benefit Determination

A decision we make about your coverage or benefits is called a benefit determination. If you believe a decision we have made adversely affects your coverage or benefits, you have a right to file an appeal. You or your authorized representative may file an internal appeal of an adverse benefit determination.

You must submit an internal appeal to us within 60 calendar days of receiving the Adverse Benefit Determination. Appeals can be submitted by phone, in writing or by fax or email.

All internal appeal requests must include the following information:

  • The covered person’s name and identification number as shown on the ID card
  • The provider’s name
  • The date of the medical service
  • The reason you disagree with the coverage denial
  • Any documentation or other written information to support your request

If you choose to submit your appeal in writing, send it to:

Attention: GA Member Appeals
P.O. Box 1947
Dayton, OH 45401

If we approve your request for benefits, we will provide you, your doctor or the ordering health partner with the appropriate notice. If we deny your internal appeal of an adverse benefit determination, we will notify you in a final adverse determination notice. 

Expedited Review of Internal Appeal

You may request an expedited internal appeal of an adverse benefit determination if taking the time for a standard resolution could seriously jeopardize your life, physical or mental health, or ability to attain, maintain or regain maximum function. If you have questions about this process, call Member Services.

We will review your request for an expedited decision. If we agree, your appeal should be expedited. We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request.

Please call us if you have any problems reading or understanding this information. We can read this out loud for you, in English or in your primary language. We also can help you if you are visually or hearing impaired. We can provide language services to help you file a complaint or appeal at no cost to you.