How and When to File an Appeal

You need to ask for an appeal within 60 calendar days from the date you get your notice of action. The date of receipt of the notice of action is presumed to be 5 days from the date located on the notice of action. You can submit an appeal in one of the following ways:

• Call Member Services at 1-855-475-3163(TTY:1-833-711-4711 or 711), Monday – Friday, 8 a.m. – 8 p.m.
• Fill out the Member Grievance/Appeal Form. If you cannot print the form, call Member Services and they can mail you one.
• Write a letter telling us what you are unhappy about. Please include:
  • Your first and last name
  • Your CareSource member ID number
  • Your address and telephone number
  • Any information that helps explain your problem

  If you have chosen an authorized representative, remember to fill out the Appointment of Representative Form.

  Mail the form or your letter to:

  CareSource
  Attn: Member Grievance & Appeals
  P.O. Box 1947
  Dayton, OH 45401-1947

  We will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us unless we tell you a different date. If your appeal is extended by CareSource, CareSource will attempt to give you prompt oral notice of the delay and send you a letter within two calendar days, which includes your right to file a grievance. We will resolve your appeal as quickly as your health condition requires.

  If we reduce, suspend or stop services before you receive all of the approved services, you will get a letter from us. Your letter will tell you how you can keep receiving the services. The letter will also tell you when you may have to pay for the services. If your request for a covered service is not approved, you can ask the state to review our decisions or actions if you do not agree with us. This is called a state hearing.

  Expedited Decision

  You or your provider can ask for a faster decision. This is called an expedited decision. Expedited decisions are for serious situations that could risk your life or health. You may need an expedited decision if a 15-day standard appeal timeframe could impact your ability to function.

  CareSource will review your expedited request within on business day of the appeal request to determine whether or not the request will be reviewed as an expedited (72 hours) or standard appeal (15 day) timeframe. If after this review, CareSource determines your request will be reviewed as a standard appeal (15-day timeframe), CareSource will make reasonable efforts to promptly notify you of this change and your right to file an expedited grievance. You will also receive a letter about the change and your rights within 2 calendar days. If your appeal remains expedited, you will receive a decision within 72 hours.

  State Hearings

  If your request for a Medicaid covered service is not approved, you can ask the state to review our decisions or actions if you do not agree with us. This is called a state hearing.

  State hearings can be requested for services primarily covered by Medicaid or both Medicare and Medicaid. You must request a state hearing within 90 calendar days after we mail a letter to you, notifying you of a decision or action.

  We will tell you of your right to ask for a state hearing. We will send you a state hearing request form when a:

  • Decision is made to deny a service.
  • Decision is made to only give partial approval for a service.
  • Decision is made to reduce, suspend or stop services that we previously approved before all of the approved services are received.
  • Provider is billing you for services. If you receive a bill, contact us as soon as possible. We will first try to contact the provider to see if they will agree to stop billing.*

  *Once your appeal has been completed, if you disagree with the outcome and your decision letter included a state hearing request form, you may request a state hearing to have your request reconsidered.

  Remember, you must have followed the CareSource appeal process before you can request a State Hearing.

  A state hearing is a meeting may include:

  • You
  • Someone from the local County Department of Job and Family Services
  • Someone from our plan
  • A hearing officer from the Ohio Department of Job and Family Services

  At a state hearing we will explain our decision. You will explain why you think we made the wrong decision. The hearing officer will decide who is right. They will decide based upon the information given and whether we followed the rules.

  If you are on the MyCare Ohio Waiver, you may have other state hearing rights. Please refer to your Home & Community-Based Services Waiver Member Handbook.

  CareSource ® MyCare Ohio (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

  CareSource Ohio, Inc. is a not-for-profit, 501(c)(3) entity. Its sole member is CareSource.

  

  Updated 08/13/2024
  H8452_OH-MYC-M-2206706a
  ODM Approved: 08/09/2024

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