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 in regard to 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:

CareSource
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 for certain health care services and treatment. If you have questions about this process, call Member Services.

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.

Review of Other Decisions

You or your authorized representative may also request a review of any decision that does not involve an adverse benefit determination. These types of decisions may cover:

  • The availability, delivery or quality of health care services
  • Claims, payments, handling or reimbursement for health care services
  • Matters involving the contractual relationship between the member and the plan

Additional Help

If you have questions about your rights or need help, please call Member Services. You may also write to us at:

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

If you have any problems reading or understanding this information, please call us. We can read the information out loud for you, in English or in your primary language. We also can help you if you are visually or hearing impaired. If you request it, we can provide language services to help you file a complaint or appeal and to notify you about your complaint or appeal. This service is available at no cost to you.

Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711) 7 a.m. to 7 p.m. Monday – Friday