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 NavigateInternal Appeal Request form. Be sure to complete the Appointment of Representative section on the form. You must return the completed form to the same location where you are sending your grievance, appeal or request for an external review.

If you cannot get this form online, you can ask that it be mailed to you by calling Member Services.

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

If you would like to file a grievance or appeal or ask for an external review, visit the links on the left side of this page. You will find helpful information about what you need to do next.

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.

Additional Help?

If you have questions about your rights or need help, please refer to the evidence of coverage for your CareSource plan 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