Grievance and Appeal

We hope you are happy with us. If you are dissatisfied with a provider, disagree with a decision we have made, or are unhappy with something about our health plan, let us know. You or your appointed representative can contact us.

You have the right to submit a:

  • Coverage Determination Request Form – A decision we make about your benefits and coverage or the amount we will pay for your medical services, items, or medications.
  • Organization Determination – A decision we make about the coverage of a service.
  • Appeal – A written request to have us reconsider and change the decision made or the action taken.
  • Grievance – A verbal or written official complaint. This process is used for certain types of problems such as quality of care, waiting times, receiving a bill and customer service.

How to Request a Coverage Determination

Online:   Fill out the Pharmacy Coverage Determination Request Form (Coming Soon)

Phone:   Call Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711).

Fax:        1-855-489-3403

Mail:       Download the  Navigate Pharmacy Coverage Determination Request Form  and mail it to:

Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Providers can complete the  Navigate Pharmacy Coverage Determination Request Form to provide supporting statements for an exception request.

How to Request an Organization Determination 

Phone:    Call Member Services at 1-833-230-2057 (TTY: 1-833-711-4711 or 711).

Online:    Fill out the Medical Coverage Determination Request Form (coming soon)

Fax:          1-844-417-6157

Mail:         Download the Medical Coverage Determination Request Form (coming soon) and mail it to:

HAP CareSource
P.O. Box 1307
Dayton, OH 45401-1307

If you are unhappy with our decision, you can appeal the decision by asking for us to reconsider the original request. Learn more in your Member Handbook/Evidence of Coverage.

Contact Medicare and Medicaid

You have the right at any time to file a complaint by contacting the:

Michigan Department of Health and Human Services
Michigan Administrative Hearing System (MDHHS)
P.O. Box 30763
Lansing, MI 48909

Phone: 1-800-648-3397
Fax: 1-517-763-0146

You can complete the Medicare Complaint Form or call 1-800-633-4227 (TTY: 1-877-486-2048 or 711), 24 hours a day, seven days a week.

Grievances, Appeals, and Exceptions Data

CareSource keeps records about the receipt and handling of grievances, appeals, and exceptions. We will also share grievances, appeals and exceptions data to you if you ask. We can also give you the total number of grievances, appeals and exceptions filed with our plans. To get this data, please call Member Services.

Request Status

Call Member Services for an update on the process or status of a decision.