File a Grievance or Appeal

We want you to be a happy CareSource® MyCare Ohio (Medicare-Medicaid Plan) member. You have the right to ask for a coverage determination for pharmacy or an organization determination for medical services. You also have the right to make a complaint (grievance) or file an appeal. If you are dissatisfied with a provider, disagree with a decision we have made, or unhappy with something about our health plan, please let us know.

If I am Not Happy, What are My Options?

We want you to understand what to do if you are not happy. You can:

  • File a complaint (also called a “grievance”) at any time
  • File an appeal, or a “redetermination” within 60 days of the date on the notice of denial received from CareSource
  • Ask for a state hearing  after you have used our appeal process
  • Report an incident (if you are on an Ohio waiver)

Always contact us as soon as possible from the day you had the problem. 

What is a Coverage Determination (Decision)?

A coverage determination is a decision made by CareSource regarding payment for a Part D drug or an exception to our formulary. If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination. You, your doctor or an appointed representative can request a coverage determination.

What is an Organization Determination (Decision)?

An organization determination is a decision made by CareSource regarding the coverage of a service. If you believe you are entitled to a medical service (Part C or Medicaid) you can request an organization determination. You, your doctor or your authorized representative can request an organization determination before or after a service (pre-service or post-service).

How to Request a Coverage Determination

To request a decision, you have the following options:

  • Online: Complete the Coverage Determination Request Form online.
  • Phone:1-855-475-3163 (TTY: 1-800-750-0750 or 711). We are open 8 a.m. to 8 p.m., Monday – Friday.  Calls to this number are free.
  • Fax: 1-855-489-3403
  • Mail: CVS Caremark, MC 109 P.O. Box 52000, Phoenix, AZ 85072-2000

Providers can complete the Coverage Determination Request Form to provide supporting statements for an exception request.

How to Request an Organization Determination 

To request a decision, you have the following options:

  • Phone:1-855-475-3163 (TTY: 1-800-750-0750 or 711). We are open 8 a.m. to 8 p.m. EST, Monday – Friday. Calls to this number are free.
  • Fax: 1-855-489-3403
  • Mail: CareSource, P.O. Box 1947, Dayton, OH 45401-1947

If you are unsatisfied with the CareSource decision, you can appeal the decision by asking for a redetermination of the original request. Full details on coverage determinations, organization determinations, and appeals can be found in your CareSource MyCare Ohio (Medicare-Medicaid) member handbook, chapter 9. Access your member handbook on the Plan Documents page.

What is a Grievance?

A grievance is an official complaint.

You have the right to file a grievance or complaint at any time. Examples of grievance include:

  • You cannot get a timely appointment.
  • You think the provider’s office staff did not treat you fairly.
  • You are not satisfied with the quality of care you received.
  • You receive a bill.

These types of grievances do not involve benefits or denial of benefits.

What is an Appeal?

An appeal is a request to reconsider and change the decision made or the action taken. An appeal is not the same as a complaint or grievance. If you do not agree with the decision/action listed in the letter (Notice of Action) you can contact us to appeal. You have the right to appeal a decision or action taken by CareSource MyCare Ohio made within 60 days of receiving the denial.

You have the right to file an appeal when:

  • CareSource denies a service or drug (medication).
  • CareSource gives partial approval to cover a service.
  • CareSource denies payment of a service or drug (medication).

What is a State Hearing?

If your request for a covered service is not approved, you may be able to ask the state to review our decision. This is called a state hearing.  Before any state hearing request, you must have followed the CareSource appeal process.  If your appeal is denied and you qualify for a state hearing you will receive a request form with the letter we send you.

Next Steps

Visit the links on the left side of this page. You will find helpful information about what you need to do next…

Plan Complaints

If you want to find out how many other people have filed complaints against CareSource MyCare Ohio, you can call Member Services at the number below. Ask about “the aggregate number of grievances, appeals and exceptions” for the Plan/Part D sponsor.

For more information, please call Member Services.

What is an Appointed Representative?

You or your appointed (authorized) representative is welcome to contact us. An appointed representative is someone you choose to act and speak on your behalf for a grievance or an appeal.

In order for CareSource MyCare Ohio to talk with your appointed representative, a CMS-1696 Appointment of Representative Form must be completed. If you cannot get this form online, call Member Services and ask that it be mailed to you. This form must be sent in every time you have someone submit a grievance, appeal or request for a decision on your behalf.


MyCare Ohio Logo Updated 09/28/2018
H8452_OHMMC-1225
CMS Approved 10/1/2018