How and When to File an Appeal

Internal Appeal of Adverse Benefit Determination

A decision we make about your coverage or benefits is called a benefit determination. If you believe a decision we have made adversely affects you, you have a right to file an appeal. You or your authorized representative may file an internal appeal of an adverse benefit determination.

If a member receives an initial denial or benefit determination, the member may file a clinical grievance. A clinical appeals nurse along with MD reviews this clinical grievance. Once this is exhausted, the member has the right to appeal. This narrative currently does not support what is happening operationally to the member’s request.

All internal appeal requests must include the following information:

  • The covered person’s name and identification number as shown on the ID card
  • The provider’s name
  • The date of the medical service
  • The reason you disagree with the coverage denial
  • Any documentation or other written information to support your request

To file an appeal, you can:

  • Select File a Grievance/Appeal in your My CareSource account.
  • Send us a letter with your appeal. Please mail the letter to:
    CareSource
    Attention: Kentucky Member Appeals
    P.O. Box 1947
    Dayton, OH 45401
  • Call Member Services to file an expedited appeal by phone.

If we approve your request for benefits, we will send you, your doctor or the ordering health partner with the appropriate notice. If we deny your internal appeal of an adverse benefit determination, we will notify you in a final adverse determination notice.

Expedited Review of Internal Appeal

You may request an expedited internal appeal of an adverse benefit determination if taking the time for a standard resolution could seriously jeopardize your life, physical or mental health, or ability to attain, maintain or regain maximum function. If you have questions about this process, call Member Services.

We will review your request for an expedited decision. If we agree, your appeal should be expedited. We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request.

You may request an expedited internal appeal of an adverse benefit determination for certain health care services and treatment. If you have questions about this process, call Member Services.

We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request.

Internal Appeal of Adverse Benefit Determination

A decision we make about your coverage or benefits is called a benefit determination. If you believe a decision we have made adversely affects your coverage or benefits, you have a right to file an appeal. You or your authorized representative may file an Navigate internal appeal of an adverse benefit determination.

You must submit an internal appeal to us within 180 days of receiving the adverse benefit determination. All internal appeal requests must be in writing, except for an internal appeal request involving urgent care, which may be requested in writing, verbally or electronically.

All internal appeal requests must include the following information:

  1. The covered person’s name and identification number as shown on the ID card;
  2. The provider’s name;
  3. The date of the medical service;
  4. The reason you disagree with the coverage denial; and
  5. Any documentation or other written information to support your request.

Mail your request to:

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

If we approve your appeal request, we will send you, your doctor or ordering health partner the appropriate notice. If we deny your internal appeal of an adverse benefit determination, we will notify you with a final adverse determination notice.

Expedited Review of Internal Appeal

You may request an expedited internal appeal of an adverse benefit determination for certain health care services and treatment. If you have questions about this process, please see Section 9 of your Evidence of Coverage or call Member Services.

We will complete an expedited review of an internal appeal of an adverse benefit determination as soon as possible given a member’s medical needs, but not later than 72 hours after we receive the request.

Review of Other Decisions

You or your authorized representative may also request a review of any decision that does not involve an adverse benefit determination. These types of decisions may cover:

  • The availability, delivery or quality of health care services;
  • Claims, payments, handling or reimbursement for health care services; or
  • Matters involving the contractual relationship between the member and the plan.

Additional Help

If you have questions about your rights or need more information, please refer to Section 9 of the Evidence of Coverage for your CareSource plan or call Member Services at 1-833-230-2099.
You may also write to us at:

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

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 request it, 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.