How and When to File an Appeal

What is an appeal? If you do not agree with a decision we make to deny a service or

benefit claim, you can file an appeal. You can also appeal when we only approve part of a claim. You have 60 days to file an appeal. You have the right to a hearing at the state level with an appeal.

Appeals Process

CareSource will send a letter when we deny a services or benefit claim.  Here are some examples of things you might file an appeal for:

  • Denial of service
  • Denial, termination, or reduction on a service that was previously approved
  • Not giving a timely service or timely appeal answer.
  • CareSource not acting in the right time frames.
  • Medically frail determination.
  • Denying part or all of the payment for a service.
  • Not giving services in a timely manner.
  • Denying your right to argue a charge, such as cost sharing.

If you file an appeal, you must ask for an appeal within 60 calendar days from the notice date. You or your authorized representative can file an appeal with CareSource. You also have a right to an expedited (fast) appeal.

You must include the items below when sending a standard or expedited appeal:

  • Your name and member ID number
  • The provider’s name
  • The date of medical service
  • The reason for your appeal
  • Information you want to attach, such as health care records or letters from your doctor
  • A phone number where we can reach you

You can file an appeal in one of these ways:

You or someone acting for you, including a provider, may file an appeal verbally or in writing. They need your written consent to act for you. We’ll send you a letter within 3 business days letting you know we got your appeal.

The people making appeal decisions are not part of prior reviews or decision making. They are health care professionals. They are supervised by our medical director. They have clinical expertise in your health condition.

Some other things to know about appeals:

  • You will be able to share proof in person or in writing.
  • Anyone acting on your behalf and with your written consent may file an appeal.
  • You can also review your case file and health records.
  • You can review any other appeal process papers free of charge.
  • CareSource will tell you when we need this information for an expedited review.

Appeal Decision

If you are at an inpatient facility, CareSource will tell the appeal decision to you and your health care provider/facility. This will be done by written notice on the day of the decision. The decision notice will be sent to you. It will also be sent to others acting for you with your written consent.

CareSource will reply to an appeal in writing as fast as your health condition requires. We will reply no later than 30 calendar days from when we got your standard appeal. We will reply within 48 hours for an expedited appeal. The member or health care provider can ask for an expedited appeal. Appeals will be expedited when CareSource decides that going by the standard timeframe could seriously harm your life, health or ability to attain, maintain or regain maximum function. If it does not meet expedited review criteria, we will tell you. We will send you a letter in two calendar days saying the matter does not meet expedited criteria. It will be handled under the standard appeal process.

You may ask for a State Fair Hearing if you do not agree with us.

Before you can ask for an external review and/or a State Fair Hearing, you must complete an internal appeal. If CareSource does not follow the notice and timing rules in this handbook, then you may ask for a State Fair Hearing before our internal appeal process is finished.

Extending the Appeal Timeframe

You or someone acting for you with your written consent can ask that CareSource extend the time frame to resolve a standard or expedited appeal up to 14 calendar days. We may also ask for up to 14 more calendar days to resolve a standard or expedited appeal. This will happen if we show that there is a need for more information and how the delay is in your best interest. We will immediately give you written notice of the reason for the extension and the date that a decision must be made

Do You Need More Help?

Please call Member Services at the number below if you have questions about your rights or need help. You may also write to us at:

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

If you have any problems reading or understanding this information, please call us. We can read the information out loud 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 offer language services to help you file a complaint or appeal and to notify you about your complaint or appeal. This service is available at no cost to you.

Member Services: 1-844-607-2829 (TTY: 1-800-743-3333), 8 a.m. to 8 p.m., Monday – Friday Eastern Time