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 Maximus, an independent review organization. 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 CareSource. You must ask for the external review within 180 days of the date of the notice of the adverse determination or final adverse determination issued by us.
You or your authorized representative may send a written You may send your standard External Review request to Maximus by mail:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534
You may also send your standard External Review request to Maximus by fax: 1-888-866-6190
If you are requesting an expedited External Review, you may submit your request by phone. Call Maximus at 1-888-866-6205.
You may submit your request to Maximus using an External Review request form. The form can be found here (https://externalappeal.cms.gov/ferpportal/public/docs/ ExtReviewReqInfoForm_20181031.pdf). If you do not use the form provided, you must still include the following to Maximus:
- Your Name
- Mailing Address
- Phone Number
- Email Address
- If Your Request is Urgent
- Consent for Your Authorized Representative, if needed
- A brief description of the reason you disagree with our denial decision (called an Adverse Benefit Determination).
Within 5 business days of Maximus’ receiving your request, they will contact us, and then we will provide Maximus within 5 days, all documents and information used to make the denial decision. After that, if Maximus determines you are not eligible for an External Review, they will contact you and us in writing.
You will also be permitted to submit any additional info you want to Maximus to consider during the External Review. Maximus will forward this additional info to us. We will review the extra information and may reconsider our denial. This reconsideration will not slow the External Review. However, the External Review may be terminated if we decide to reverse our decision and provide coverage or payment. We will notify you and Maximus in writing within 1 business day after reversing our decision. Maximus should then terminate the External Review when they receive our notice.
If you need help reading 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 ask, 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.