Part C Medical Plan Rights

Organization Determinations (Decisions)

A decision we make about the coverage of a service. If you believe you are entitled to a medical service (Part C or Medicaid) you can request an organization determination.

Who Can Ask for an Organization Determination?

  • You
  • Your appointed representative
  • Your provider

Full details for these requests can be found in the Evidence of Coverage (EOC) in Chapter 9, section 4 on Plan Documents page.

How to Request an Organization Determination

You have these options:

  • Phone: Call Member Services at 1-833-230-2020 (TTY: 1-833-711-4711 or 711). 
  • Mail: CareSource, P.O. Box 1947, Dayton, OH 45401-1947

Appeals

An appeal is a request to reconsider and change the decision made or the action taken on services requested. An appeal is not the same as a complaint or grievance.

Who Can Ask for an Appeal?

  • You
  • Your appointed representative
  • Your provider

Appeals are filed after getting back the organization determination or decision.

There are 5 levels of appeals. Details of these levels can be found in Chapter 9 in sections 8 and 9 of the Evidence of Coverage on our Plan Documents page.

Asking for an Appeal

You have 60 days from the date on your organization determination to file an appeal. More time may be given based on your situation. If you file an appeal after those 60 days, include a written statement of Good Cause to ask that your appeal be reviewed past the limit.

How to Request an Appeal

You have these options:

  • Phone: Call Member Services at 1-833-230-2020 (TTY: 1-833-711-4711 or 711). 
  • Mail: CareSource, P.O. Box 1947, Dayton, OH 45401-1947

If your first appeal is denied or if you disagree with any part of our appeal decision, you can request further appeal levels.

Grievances

An official complaint. You have the right to file a grievance or complaint at any time.

Who Can Ask for a Grievance?

  • You
  • Your appointed representative

How to File a Grievance 

You have these options:

  • Phone: Call Member Services.
  • Mail: You can file one in writing. Complete the Grievance Form and send it to: CareSource

P.O. Box 1947
Dayton, OH 45401-1947.

Is your complaint about quality of care? You can make your complaint to the Quality Improvement Organization (QIO). Find the name, address and phone number of the QIO for your state in your Evidence of Coverage in Chapter 2, section 4 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.

See more about grievances in Chapter 9, section 10 in your Evidence of Coverage on our Plan Documents page.

Grievances, Appeals, and Exceptions Data

CareSource keeps records about the receipt and handling of grievances, appeals, and exceptions. We will also share grievances, appeals and exceptions data to you if you ask. We can also give you the total number of grievances, appeals and exceptions filed with our plans. To get this data, please call Member Services.

Request Status

Call Member Services for an update on the process or status of a decision.

Appointing a Representative

You can have a relative, friend, advocate, provider or other person who can act on your behalf in filing a grievance, coverage determination, organization determination or appeal. We call these people appointed representatives.

Those not authorized under state law to act for you will need to sign an Appointment of Representative Form. Complete it by

CareSource Member Services at 1-833-230-2020 (TTY: 1-833-711-4711 or 711). We are open 8 a.m. to 8 p.m. Monday through Friday, and from October 1 through March 31 we are open the same hours, seven days a week.