State Hearing and External Review

External Review Process

If you are unhappy with a CareSource decision made in response to an internal appeal you filed, 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.

External reviews are conducted by independent review organizations. You do not have to pay for an external review and you will not be subject to retaliation for requesting an external review. 

You or your authorized representative may request an external review of an adverse benefit determination or a final adverse determination notice by contacting the Offices of the Insurance Commissioner of the State of West Virginia. You must ask for the external review within 120 days of the date of the notice of the adverse determination or final adverse  determination issued by us. 

All external review requests must be in writing, except for a request for an expedited external review, which may be requested verbally. In addition to filing the request for external review, you will also be required to authorize the release of your medical records as necessary to conduct the external review.

You or your authorized representative may send a written request for an external review to:

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

If you have questions about your rights or need help, please call Member Services at 1-855-202-0622 (TTY for the hearing impaired: 1-800-982-8771 or 711).

If you are not able to resolve a complaint with CareSource, you may contact the West Virginia Department of Insurance at:

West Virginia Offices of the Insurance Commissioner
ATTN:  Consumer Service Division
P.O. Box 50540
Charleston, WV 25305-0540

Consumer Hotline: 1-888-879-9842

Fax: 1-304-558-4965

Website: www.wvinsurance.gov

If you have any problems reading or understanding 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 request it, 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.

Member Services: 1-855-202-0622 (TTY: 1-800-982-8771 or 711), Monday through Friday, 7 a.m. to 7 p.m.