Grievance and Appeal

We hope you are happy with CareSource. 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.

An appointed representative is someone you choose who can act and speak on your behalf. In order for CareSource MyCare Ohio to talk with your appointed representative, must fill out the Appointment of Representative Form. Call Member Services to have the form mailed to you. This form must be sent each time you have someone submit a grievance, appeal or request for a decision on your behalf.

You have the right to submit a:

  • Coverage Determination – 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 request to have us reconsider and change the decision made or the action taken.
  • Grievance– An 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

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.

Online: Fill out the Navigate Coverage Determination Request Form 

Fax: 1-855-489-3403

Mail: Download the Navigate Coverage Determination Request Form  and mail it to:
Express Scripts
c/o Medicare Clinical Appeals,
P.O. Box 66588
St. Louis, MO 63166-6588

How to Request an Organization Determination 

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.

Online: Fill out the Navigate Coverage Determination Request Form

Fax: 1-844-417-6157

Mail: Download the Navigate Coverage Determination Request and mail it to:
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. Find more information in your Evidence of Coverage (EOC) or Medicaid-Only Member Handbook.