We Want You to be Happy!
We hope you are happy with your CareSource benefits and services. If you are dissatisfied with a provider, disagree with a decision we have made, or are you are unhappy with something about our health plan, let us know. You or your authorized representative is welcome to contact us.
An authorized representative is someone you choose who can act and speak on your behalf.
In order for CareSource to talk to your authorized representative, you and your authorized representative must complete the HIPAA Authorization Form. You may complete the form online or download this hard-copy version. You must return the completed form to the same location where you are sending your grievance, appeal or request for an external review.
If you cannot get this form online, you can ask that it be mailed to you by calling Member Services.
If you are not satisfied, you have the right to:
- File a complaint (also called a grievance)
- File an appeal
- Ask for an external review
If you would like to file a grievance or appeal or ask for an external review, visit the links on the left side of this page. You will find helpful information about what you need to do next.
WHAT IS A GRIEVANCE?
A grievance is an official complaint. You have the right to file a grievance when:
- You cannot get a timely appointment with a provider.
- You think the provider’s office staff did not treat you fairly.
- You are not satisfied with the quality of care you received.
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.
For more specific information about any of these topics, please see your plan’s Evidence of Coverage on the Plan Documents page.
What is an External Review?
External reviews are conducted by Independent Review Organizations. If you are unhappy with a CareSource decision made in response to an internal appeal that 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.
NEED ADDITIONAL HELP?
If you have questions about your rights or need help, please refer to the evidence of coverage for your CareSource plan or call Member Services at 1-855-202-0622 (TTY for the hearing impaired: 1-800-982-8771 or 711).
You may also write to us at:
Attention: West Virginia 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 is a free service.