State Hearing and External Review

External Review Process

If you are unhappy with a CareSource decision made in response to an internal appeal you filed, you may request an external review. In most cases, you must go through all of the steps in the internal appeal process before you can ask for an external review.

External reviews are conducted by independent review organizations or the Kentucky Department of Insurance. You do not have to pay for an external review, and you will not be subject to retaliation for requesting an external review.

You or your authorized representative may request an external review of a denial (an adverse benefit determination or a final adverse determination notice) for clinical denials by contacting CareSource and for coverage denials by contacting the Kentucky Department of Insurance. You must ask for an external review within 120 days of the date of the notice of the adverse determination or final adverse determination was issued by us.

If the adverse decision is related to a denial issued due to the member’s failure to follow the plan delivery rules, or you have a general complaint, you may submit an appeal or complaint in writing to the address below, or you can fill out an online complaint form.

Kentucky Department of Insurance
Division of Consumer Protection
P.O. Box 517 Frankfort, KY 40602

All external review requests must be in writing, except when requesting an expedited external review, which may be requested verbally by calling Member Services. State your reason(s) for appealing the denial and submit copies of any documentation that supports your position.

In addition to filing the request for external review, you will also be required to authorize the release of your medical records as necessary to conduct the external review.

You or your authorized representative may send a written request for an external review to:

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

If you need help reading this information, please call us. We can read the information aloud for you, in English or in your primary language. We also can help you if you are visually or hearing impaired. If you ask, we can provide language services to help you file a complaint or appeal and to notify you about your complaint or appeal. This is a free service.