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, you and your authorized representative must complete the Appointment of Representative form or the Navigate Internal Review Request form. Return the completed forms to us along with your grievance, or request for an external review. These forms are available 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 grievance related to a denial of benefits (Adverse Benefit Determination)
  • Ask for an external review

What is a Grievance?

A grievance is an official complaint. 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. 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.
  • You receive a surprise bill from your provider.

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 for an external review.

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 a grievance 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 review process before you can ask for an external review.

Additional Help?

For more specific information about these topics, refer to Section 9 in your Evidence of Coverage or call Member Services at 1-833-230-2099 (TTY: 711).

You may also write to us at:

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