How and When to File an Appeal
You may request an expedited internal appeal of an adverse benefit determination if taking the time for a standard resolution could seriously jeopardize your life, physical or mental health, or ability to attain, maintain or regain maximum function. If you have questions about this process, call Member Services.
We will review your request for an expedited decision. If we agree, your appeal should be expedited. 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.
How to Contact Us
You need to let us know within 60 calendar days from the date of your Notice of Action to ask for an appeal.
You can tell us about your complaint or grievance in a way that’s convenient for you.
- Call Member Services at 1-855-475-3163 (TTY: 1-800750-0750 or 711), Monday – Friday, 8 a.m. – 8 p.m.
- Fill out the Member Grievance/Appeal Form.
If you cannot print the form, call Member Services and they can mail you one.
- Write a letter telling us what you are unhappy about. Include your first and last name, your CareSource member ID number and your address and telephone number. Be sure to tell us any information that helps explain your problem.
- If you have chosen an authorized representative, remember to complete the Appointment of Representative Form.
Mail the form or your letter to:
Attn: Member Grievance & Appeals
P.O. Box 1947
Dayton, OH 45401-1947
Or fax the form to 1-855-489-3403.
How to Contact Medicare and Medicaid
You also have the right at any time to file a complaint by contacting the:
Ohio Department of Medicaid
Bureau of Managed Care
P.O. Box 182709
Columbus, Ohio 43218-2709
If you are a MyCare member who is covered by CareSource for both Medicare and Medicaid, you have the right at any time to file a complaint about your health care plan with Medicare by completing the online Medicare Complaint Form or by calling 1-800-Medicare. (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048 or 711.
Our Commitment to You
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.
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 a 15-day delay could impact your ability to function.
If we decide that your health condition needs an expedited decision, we will make the decision as quickly as needed. The decision will be no later than 72 hours after the request is received. We will notify you if we deny the request to expedite the decision. We will then resolve your appeal in the 15-day timeframe. We will notify you in writing within three calendar days.
If we made a decision to reduce, suspend or stop services before you receive all of the 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 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.
State hearings can be requested for services primarily covered by Medicaid or both Medicare and Medicaid. You must request a state hearing within 120 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.
- 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.*
*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 followed the CareSource appeal process before you can request a State Hearing.
A state hearing is a meeting that includes:
- 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. He/she will decide based upon the information given and whether we followed the rules.
If you are on the MyCare Ohio Waiver, you may have other state hearing rights. Please refer to your Home & Community-Based Services Waiver Member Handbook.
Member Services: 1-855-475-3163 (TTY: 1-800-750-0750 or 711), 8 a.m. to 8 p.m., Monday – Friday.