File a Grievance or Appeal
We Want You To Be Happy!
We hope you are happy with your CareSource benefits and services. If you are dissatisfied with a provider, disagree with a decision we have made, or are you are unhappy with something about our health plan, let us know. You or your authorized representative is welcome to contact us.
An authorized representative is someone you choose who can act and speak on your behalf.
In order for CareSource to talk to your authorized representative regarding your grievance or appeal, you and your authorized representative must complete the Appointment of Representative form or the Internal Appeal Request form. Return the completed form to us along with your grievance, appeal, or request for an external review. These forms are available online on the Forms page or by calling Member Services for printed copies.
If you are not satisfied, you have the right to:
- File a complaint (also called a grievance)
- File an appeal
- Ask for an external review
What is a Complaint?
We have a Complaint Process for the quick resolution of complaints you submit to us that are unrelated to benefits denials. For purposes of this process, a complaint is saying you are unhappy or dissatisfied with any aspect of our operation.
If you have a complaint concerning us, please contact us. You have the right to file a complaint when:
- You cannot get a timely appointment with a provider.
- You think the provider’s office staff did not treat you fairly.
- You are not satisfied with the quality of care you received.
We will send you a letter telling you the outcome of the complaint review. If you do not agree with the decision, you can file an appeal.
What is an Appeal?
You have the right to file an Internal Appeal with us if you disagree with or are dissatisfied with our decision concerning any of the review requests listed below. The timing of decisions and notifications related to such Internal Appeals are provided below.
- CareSource denies a service.
- CareSource gives partial approval to cover a service.
- CareSource denies payment of a service.
- You receive a surprise bill from your provider.
For more specific information about any of these topics, please see Section 9 in your plan’s Evidence of Coverage on the Plan Documents page.
What is an External Review?
External reviews are conducted by Independent Review Organizations. If you are unhappy with a CareSource decision made in response to an internal appeal that you filed regarding a denial to cover or pay for a service, 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.
Additional Help?
If you have questions about your rights or need help, please refer to your Evidence of Coverage or call Member Services at 1-833-230-2099 (TTY: 711).
You may also write to us at:
CareSource
Attention: Kentucky Member Appeals
P.O. Box 1947
Dayton, OH 45401