Part C Medical Plan Rights
Organization Determinations (Decisions)
An organization determination is a decision (approval or denial) made by CareSource regarding payment of benefits.
Requesting an Organization Determination
As a member of CareSource Medicare Advantage, you, your appointed representative or your physician may request an organization determination. Full details on organization determination requests can be found in the Evidence of Coverage (EOC) (Chapter 9, section 4). To locate this document and more, visit our Plan Documents page.
How to Request an Organization Determination
To request a decision, you have the following options:
- Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday Calls to this number are free.
- Fax: 1-844-417-6153
- Mail: CareSource, P.O. Box 1432, Dayton, OH 45401-1432
Appeals
If you are unsatisfied with the outcome of an organization determination, you can ask for an appeal. When you make an appeal, CareSource will review your unfavorable coverage determination or organization determination.
The first level of appeal for Part C is called reconsideration. You may file for Part C reconsideration if you want CareSource to reconsider a decision regarding payment or benefits to which you believe you are entitled. There are five levels of appeals. Details of all levels can be found in the Evidence of Coverage (Chapter 9, sections 8 and 9). To locate this document and more, visit our Plan Documents page.
Requesting an Appeal
As a CareSource member, you, your appointed representative or your prescribing physician may file for an appeal of an organization determination.
Appeals must be filed within 60 calendar days of the date included on the notice of the CareSource organization determination. More time may be granted depending on circumstances.
How to Request an Appeal
To file a standard Part C reconsideration (appeal), you have the following options:
- Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday. Calls to this number are free.
- Fax: 1-844-417-6153
- Mail: CareSource, P.O. Box 1432, Dayton, OH 45401-1432
If your first appeal is denied or if you disagree with any part of our appeal (redetermination or reconsideration) decision, you can request further appeal levels. Complete details on all appeal levels can be found in the Evidence of Coverage (Chapter 9, sections 8 and 9). To locate this document and more, visit our Plan Documents page.
Request Status
For questions regarding the process or status of a coverage determination, organization determination, redetermination or reconsideration request, you or your appointed representative should call CareSource at the following toll-free number:
Call Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday
Grievances
A grievance is any dispute (other than one involving a coverage determination or an organization determination) that expresses dissatisfaction with the operations, activities or behavior of CareSource or one of our providers. Complete details on grievances can be found in the Evidence of Coverage (Chapter 9, section 10). This document and others are available on our Plan Documents page.
Examples of grievances:
- Unresolved issues with Member Services
- Problems with one of our network providers
- Problems with waiting times at your physician’s office
- Suspicion of fraud or abuse
- Marketing or sales activities you feel are inappropriate
How to File a Grievance
To file a grievance, you have the following options:
- Phone: If you would like to file a verbal grievance, you can call Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday. Calls to this number are free.
- Mail: If you would like to file a grievance in writing, complete the Grievance Form and send it to CareSource, P.O. Box 1432, Dayton, OH 45401-1432.
When your complaint is about quality of care, you can make your complaint to the Quality Improvement Organization (QIO). To find the name, address and phone number of the QIO for your state, look in your Evidence of Coverage (Chapter 2, section 4). This document and others are available on our Plan Documents page.
You can submit feedback directly to Medicare by using the Medicare Complaint Form. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
Grievances, Appeals, and Exceptions Data
CareSource tracks and maintains records about the receipt and handling of grievances, appeals, and exceptions. We will also disclose grievances, appeals and exceptions data to you upon request. CareSource can also provide an aggregate number of grievances, appeals and exceptions filed with our plans. To obtain this data, please call CareSource Member Services: 1-855-852-7005 (TTY: 1-800-648-6056 or 711), 7 a.m. – 7 p.m., Monday – Friday
Appointing a Representative
An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal.
Those not authorized under state law to act for you will need to sign an Appointment of Representative Form and mail it to P.O. Box 1432, Dayton, OH 45401-1432.
CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage® Zero Premium (HMO), CareSource Advantage® (HMO) and CareSource Advantage Plus® (HMO) depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Updated XX/XX/XXXX Y0119_OHMA-M-0251
Pending CMS Approval