File a Grievance or Appeal
Grievances and Noncertifications
We hope you will be happy with CareSource and the service we provide. If you are unhappy with anything about CareSource or our providers, let us know as soon as possible. Even if you do not agree with a decision we have made, please contact Member Services. You or your authorized representative can contact us with a complaint.
In order for CareSource to talk to your authorized representative about your grievance or appeal, you and your authorized representative must complete the Appointment of Authorized Representative form or the HIPAA Authorization form. Return the completed form to us by mail or fax.
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 grievance or complaint
- File an appeal
- Ask for an external review
What is a Grievance?
You can file a grievance when you are unhappy or unsatisfied with CareSource or a provider and how they do business.
Examples of a reason to file a grievance might be:
- 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 may be filed when you want a review of a noncertification or Adverse Benefit Determination and is separate from the grievance process. There is one level of review for both grievances and appeals.
Examples of a reason to file an appeal might be:
- CareSource denies a service.
- CareSource gives partial approval to cover a service.
- CareSource denies payment of a service.
You can ask for an expedited appeal. You must request an appeal in writing within 180 days of the date you receive notice of an adverse event like a denial of service. You can find an Internal Appeal Request form online on the Forms page under Tools and Resources.
What is an External Review?
External reviews are conducted by Independent Review Organizations. If you are unhappy with CareSource upholding a noncertification made in response to an internal appeal process you filed regarding a denial to cover or pay for a service, you may request an external review. In most cases, you must go through all the steps in the internal appeal process before you can ask for an external review.
The state of North Carolina has resources to help you with external reviews at no cost to you. Smart NC helps you file health insurance appeals and complaints, submit external review requests for denied health insurance services or products, and receive counseling regarding your rights under North Carolina laws. Services are provided at no cost to you.
North Carolina Department of Insurance
Health Insurance Smart NC
1201 Mail Service Center
Raleigh, NC 27699-1201
855-408-1212 (toll free)
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. You can get help in another language in or in another format such as large print, audio or Braille also. Call Member Services for help.