File a Grievance or Appeal
We Want You to be Happy!
We hope you are happy with your CareSource benefits and services. If you are dissatisfied with a provider, disagree with a decision we have made, or are you are unhappy with something about our health plan, let us know. You or your authorized representative is welcome to contact us.
An authorized representative is someone you choose who can act and speak on your behalf.
In order for CareSource to talk to your authorized representative regarding your grievance or appeal, you and your authorized representative must complete the Appointment of Representative form or the Internal Appeal Request form. Return the completed form to us along with your grievance, appeal, or request for an external review. These forms are available online on the Forms page or by calling Member Services for printed copies.
If you are not satisfied, you have the right to:
- File a complaint (also called a grievance)
- File an appeal
- Ask for an external review
What is a Grievance?
A grievance is an official complaint. This is the first step of the review process 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. You have the right to file a grievance when:
- You cannot get a timely appointment with a provider.
- You think the provider’s office staff did not treat you fairly.
- You are not satisfied with the quality of care you received.
- CareSource denies a service.
- CareSource gives partial approval to cover a service.
- CareSource denies payment of a service.
We will send you a letter letting you know the outcome of the grievance review. If you do not agree with the decision, you can file an appeal
What is an Appeal?
If you do not agree with the outcome of the grievance, you have the right to appeal. An appeal is a request to reconsider and change the decision made or the action taken.
For more specific information about any of these topics, please see your plan’s Evidence 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 CareSource decision made in response to an internal appeal that you filed regarding a denial to cover or pay for a service, you may request 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.
If you have questions about your rights or need help, please refer to your Evidence of Coverage or call Member Services.
Member Services: 1-855-202-0622 (TTY: 1-800-982-8771 or 711)
You may also write to us at:
Attention: West Virginia Member Appeals
P.O. Box 1947
Dayton, OH 45401