Member Rights & Responsibilities

Member Rights

As a CareSource health plan member, it’s important to understand your rights. You have the right to:

  • Receive information about covered services, network providers and member rights and responsibilities.
  • Be treated with respect and dignity by our employees, contracted providers, vendors, and health care professionals.
  • Privacy and confidentiality regarding your health and care.
  • Participate with providers in making decisions about your health care.
  • A candid discussion about appropriate or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage.
  • Voice complaints or concerns about us or any of our network providers.
  • Appeal any decision made by us and to receive a response within a reasonable amount of time.
  • Choose an advance directive to designate the kind of care you wish to receive should you become unable to express your wishes.
  • Have a safe, secure, clean, and accessible health care environment.
  • Have access to emergency health care services in cases where a “prudent layperson” acting reasonably would believe that an emergency existed.
  • Make recommendations regarding the organization’s member rights and responsibilities policy.

Member Responsibilities

When you buy health insurance, you also have certain responsibilities. You need to:

  • Pay your premium.
  • Comply with all provisions of the policy that are outlined in the Certificate of Coverage. This includes Prior Authorization
  • Know and confirm your benefits before receiving treatment.
  • Show your ID card before receiving health care services.
  • Follow agreed upon instructions and guidelines for care.
  • Understand your health problems and develop mutually agreed upon treatment goals, to the degree possible.
  • Provide accurate information, to the extent possible, as required to care for you, or to make an informed coverage determination.
  • Use in-network providers for health care benefits and services, except where services are authorized by CareSource, or in the event of emergencies.
  • Pay your cost-share amount (copay, coinsurance, deductible) to your network provider when services are received.
  • Pay the full billed amount for non-covered services such as non-emergency out-of-network services.

File a Grievance or Appeal

We want you to be happy with your CareSource benefits and services. 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 authorized representative have the right to:

  • File a complaint (also called a grievance)
  • File an appeal
  • Ask for an external review

Authorized Representative

In order for CareSource to talk to your authorized representative, you and the person that you appoint must complete the Appointment of Representative form. Return the completed form to us along with your grievance, appeal, or request for an external review. You can get these on the Forms page or by calling Member Services to ask for printed copies.

What is a Grievance?

A grievance is an official verbal or written complaint. You can file a grievance if you are unhappy with your benefits and services such as:

  • Not being able to get a timely appointment with a provider.
  • A provider’s office staff not treating you fairly.
  • Not being satisfied with the quality of care you received.
  • A partial approval to cover a service.
  • A service payment denial.
  • A surprise bill from your provider.

What is an Appeal?

If you do not agree with the decision CareSource made, you have the right to appeal. An appeal is a request to reconsider and change a decision made or the action taken. For more specifics about your right to appeal, please see your plan’s Certificate of Coverage on the Plan Documents page.

What is an External Review?

External reviews are conducted by Independent Review Organizations. If you are unhappy with a decision we made in response to your appeal of a denial to cover or pay for a service, you may ask for an external review. In most cases, you must go through all of the steps in the internal appeal process before you can ask for an external review.

Need Help?

For more specifics about your right to appeal, the appeal process, and the time needed to make a decision, please see your plan’s Certificate of Coverage (COC). You may also call Member Services at 1-877-514-2442 (TTY: 711) or write to us at:

CareSource
Attention: WI Member Appeals
P.O. Box 1947
Dayton, OH  45401