How and When to File an Appeal
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 regarding 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.
Internal Appeal of Adverse Benefit Determination
A decision we make about your coverage or benefits is called a benefit determination. If you believe a decision we have made adversely affects your coverage or benefits, you have a right to file an appeal. You or your authorized representative may file an internal appeal of an adverse benefit determination.
You must submit an internal appeal to us within 60 calendar days of receiving the Adverse Benefit Determination. Appeals can be submitted by phone, in writing or by fax or email.
All internal appeal requests must include the following information:
- The covered person’s name and identification number as shown on the ID card
- The provider’s name
- The date of the medical service
- The reason you disagree with the coverage denial
- Any documentation or other written information to support your request
If you choose to submit your appeal in writing, send it to:
Attention: Ohio Member Appeals
P.O. Box 1947
Dayton, OH 45401
If we approve your request for benefits, we will provide you, your doctor or the ordering health partner with the appropriate notice. If we deny your internal appeal of an adverse benefit determination, we will notify you in a final adverse determination notice.
Expedited Review of Internal Appeal
You may request an expedited internal appeal of an adverse benefit determination for certain health care services and treatment. If you have questions about this process, call Member Services.
We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request, if the request meets the criteria for an expedited appeal.
Review of Other Decisions
You or your authorized representative may also request a review of any decision that does not involve an adverse benefit determination. These types of decisions may cover:
- The availability, delivery or quality of health care services
- Claims, payments, handling or reimbursement for health care services
- Matters involving the contractual relationship between the member and the plan
Please call member services if you have questions. You may also write to us at:
Attn: OH Member Appeals
P.O. Box 1947
Dayton, OH 45401
If you do not agree with a decision we have made about your benefits, you can appeal it. If you do not agree with the result of the appeal, you can ask for a state hearing. A state hearing is when our decision or action is reviewed by the state. It is a meeting that includes:
- Someone from the county Department of Job and Family Services
- Someone from our plan
- A hearing officer from the Ohio Department of Job and Family Services
Your appeal could be the result of when a:
- Decision is made to deny a service
- Decision is made to only give partial approval for a service
- Decision is made to reduce, suspend or stop services that we previously approved before all of the approved services are received
- Provider is billing you for services. If you receive a bill, contact us as soon as possible. We will first try to contact the provider to see if he/she will agree to stop billing.
We will tell you of your right to ask for a state hearing if we do not change our decision as part of your appeal. We will send you a state hearing form. You will have 90 days from the mailing date of the form to request a hearing. You must follow our appeal process before you can ask for a state hearing.
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. He/she will decide based upon the information given and whether we followed the rules.
Member Services: 1-800-488-0134 (TTY: 1-800-750-0750 or 711), Monday – Friday 7 a.m. – 8 p.m.