How and When to File an Appeal

There are two types of grievances. One is when you are unhappy with a service or provider. This is called a standard grievance. The second type is when you are unhappy with a decision we’ve made about a benefit or coverage. You can file a grievance if you are unhappy with your benefits and services or if you do not agree with a decision that was made regarding your medical care.

Note: Please refer to Section 9 of your Evidence of Coverage for timeframes for CareSource’s review of grievances and expedited grievances.

Grievance of an 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 you, you have a right to file an grievance. You or your authorized representative may file a grievance.

You must submit an internal grievance to us within 180 days of receiving the adverse benefit determination. All internal grievance requests must be in writing, except for an internal grievance request involving urgent care, which may be requested in writing, verbally or electronically.

All internal grievance 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; and
  • Any documentation or other written information to support your request.

Mail your request to:

CareSource
Attention: West Virginia Member Reviews
P.O. Box 1947
Dayton, OH 45401

If we approve your grievance request, we will send you and your doctor or ordering health partner the appropriate notice. If we deny your internal grievance of an adverse benefit determination, we will send you a final adverse determination notice. 

Expedited Grievance of an Adverse Benefit Determination 

You may request an expedited internal grievance of an adverse benefit determination for certain health care services and treatment. If you have questions about this process, please see Section 9 of your Evidence of Coverage or call Member Services.

We will complete an expedited review of an internal grievance for 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.

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; or
  • Matters involving the contractual relationship between the member and the plan.

Additional Help

If you need help or want more details about this process, please refer to Section 9  of the Evidence of Coverage for your CareSource plan or call Member Services at the number below. 

You may also write to us at:

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

If you need help reading this information, please call us. We can read the information aloud for you, in English or in your primary language. We also can help you if you are visually or hearing impaired. If you ask, we can provide language services to help you file a complaint or appeal and to notify you about your complaint or appeal. This is a free service.