Appeals

What is an Appeal?

An appeal is when you ask us to review a decision that denied a benefit or service.

The Appeal Process

If you believe a decision we have made adversely affects your coverage or benefits, you have a right to file an appeal. You need to ask for an appeal within 60 calendar days from the date you get your Notice of Action. We presume the date you get the Notice of Action to be five (5) days from the date printed on the notice. You can submit an appeal in one of these ways:

Online: File an appeal by signing into your CareSource MyLife account.

Phone: Call Member Services at 1-855-475-3163 (TTY: 1-833-711-4711 or 711). We are open Monday through Friday, 8 a.m. to 8 p.m. Eastern Time, and from October 1 through March 31 we are open the same hours, seven days a week.

Mail: Write a letter telling us what you are unhappy about. Please include your first and last name, your member ID number, your address, phone number and any information that helps explain your problem. Mail the form or letter to:

CareSource
Attn: Member Grievance & Appeals
P.O. Box 1947
Dayton, OH 45401-1947

Fax: You or your provider can send a fax to 937-531-2398.

If you have chosen an authorized representative, remember to fill out the Appointment of Representative Form.

We will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us unless we tell you a different date. If your appeal is extended by CareSource, we will attempt to give you prompt oral notice of the delay and send you a letter within two calendar days, which includes your right to file a grievance. We will resolve your appeal as quickly as your health condition requires.

If we reduce, suspend or stop services before you receive all approved services, you will get a letter from us. Your letter will tell you how you can keep receiving the services. The letter will also tell you when you may have to pay for the services. If your request for a covered service is not approved, you can ask the state to review our decisions or actions if you do not agree with us. This is called a state hearing.

Expedited Decision

You or your provider can ask for a faster decision. This is called an expedited decision. Expedited decisions are for serious situations that could risk your life or health. You may need an expedited decision if waiting up to15 days for a standard appeal decision could impact your ability to function.

CareSource will review your request for an expedited appeal within one (1) business day. We will determine if the appeal will be reviewed as an expedited appeal within 72 hours or as a standard appeal within 15 days. If after the review we determine your appeal will be reviewed as a standard appeal under the 15-day timeframe instead of as an expedited appeal, we will make reasonable efforts to promptly notify you of this decision and your right to file an expedited grievance. You will also receive a letter within two (2) calendar days that tells you about the change and your rights. If your appeal remains expedited, you will receive a decision on your appeal within 72 hours.

State Hearings

If your request for a Medicaid covered service is not approved, you can ask the state to review our decisions or actions if you do not agree with us. This is called a state hearing.

State hearings can be requested for services primarily covered by Medicaid or both Medicare and Medicaid. You must request a state hearing within 90 calendar days after we mail a letter to you notifying you of a decision or action.

We will tell you of your right to ask for a state hearing. We will send you a state hearing request form when:

  • A decision is made to deny a service.
  • A decision is made to give only partial approval for a service.
  • A decision is made to reduce, suspend or stop services that we previously approved before all of the approved services are received.
  • A provider is billing you for services. If you receive a bill, contact us as soon as possible. We will try to contact the provider first to see if they will agree to stop billing.*

*Once your appeal has been completed, if you disagree with the outcome and your decision letter included a state hearing request form, you may request a state hearing to have your request reconsidered.

Remember, you must have gone through the full CareSource appeal process before you can request a State Hearing.

A state hearing is a meeting may include:

  • You
  • Someone from the local County Department of Job and Family Services
  • Someone from our plan
  • A hearing officer from the Ohio Department of Job and Family Services

At a state hearing we will explain our decision. You will explain why you think we made the wrong decision. The hearing officer will decide who is right. They will decide based upon the information given and whether we followed the rules.

Extending an Appeal

You may request that CareSource extend the timeframe to resolve any medically necessity appeal request by up to 14 days. CareSource may also request an extension of up to 14 days, if the extension is in your best interest, such as to obtain additional needed information. CareSource will make reasonable efforts to provide you with prompt oral notification of the delay and your right to file a grievance about this decision. CareSource will notify you and your authorized representative in writing of the decision to extend the timeframe, the reason for the extension, and your grievance rights within two (2) calendar days. CareSource will resolve the appeal as quickly as the member’s health condition requires but no later than the date the extension expires. Part B drug appeals may not be extended.

Learn more about appeals in your Evidence of Coverage (EOC) or Medicaid-Only Member Handbook.

Questions? Call Member Services at 1-855-475-3163 (TTY: 1-833-711-4711 or 711). We are open Monday through Friday, 8 a.m. to 8 p.m. Eastern Time, and from October 1 through March 31 we are open the same hours, seven days a week.