How and When to File an Appeal

We follow all federal civil rights laws. We don’t discriminate based on:

  • race
  • color
  • national origin
  • age
  • disability
  • sex

We hope you are happy with HAP CareSource. If you are dissatisfied with a provider, disagree with a decision we have made, or are unhappy with something about our health plan, let us know. You or your authorized representative can contact us.

Grievance cases are:

  • Quality of health care services, like safety issues
  • Access and availability of care
  • Attitude and service of providers, office staff or HAP CareSource staff
  • The benefits in your plan

By phone: 1-833-230-2053 (TTY: 711)

Member Services is here to help. They can help you write a grievance. This can be done by phone, online or in writing. We also have translator services.

Online: MyCareSource.com

By mail:

HAP CareSource
Attn: Grievance & Appeals
P.O. Box 1025
Dayton, OH 45401-1025

  • Your doctor or an approved person may file a grievance for you
  • We’ll send you a letter within five days that acknowledges receipt of the grievance.
  • We’ll fully investigate your grievance.
  • We’ll send you an answer in writing no later than 90 days from the date we received your grievance.
    • We may extend the time frame by up to 14 days if you ask for an extension. Or, if we need more information and think the delay is in your best interest. If we extend the time, we’ll call and let you know. We’ll also mail you a letter reminding you we’re extending our time. If you’re not happy we need more time, you can call or write to us and let us know.

Appeals

Pre-service/post-service appeals

  • You can file an appeal if we deny, suspend, end or reduce a covered health care service. Samples are 
    • Not approving or paying for a covered service or item your doctor asks for
    • Stopping a service approved in the past
  • If we decide to reduce or stop a service, you can keep getting the service until we make a final ruling. You can also keep getting the service while you’re waiting for a ruling from the State Fair Hearing.
  • You have 60 calendar days from the date on the denial notice to file an appeal.
  • You can do this online, in writing, or by phone.
  • You can choose someone to represent you.
  • Once we get your appeal request, we’ll review your request and mail you a ruling within 30 calendar days or 10 calendar days if you are enrolled in the CSHCS program. We can extend this time by an extra 14 days if you ask us to. Or, if we think giving extra time is in your best interest.
  • You can ask for a state fair hearing if we deny your pre-service or post-service appeal. It must be within 120 days of the date on the appeal denial notice.

Call the state of Michigan at 1-800-642-3195 to have a hearing request form (DCH-0092) sent to you. Fill out the form and return it to the address on the form.

If you’re unhappy with our finding or we don’t give a ruling on your appeal within 30 days, you can ask for an outside review from the Department of Insurance and Financial Services. Your request must be in writing within 127 days from date of the appeal decision and sent to:

Department of Insurance and Financial Services
Office of General Counsel – Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720

Expedited pre-service appeal

If you or a doctor say the 30-calendar-day time frame could harm your health, your pre-service appeal will be an expedited request if it meets our criteria. These appeals are handled in 72 hours. 

Outside Medical review by the Department of Insurance and Financial Services (DIFS)

You must appeal in writing to the DIFS within 127 calendar days of the ruling. You must complete HAP CareSource’s appeal process before asking for review from the DIFS. The appeal coordinator will explain the outside review process. We can also mail the outside review forms to you.

DIFS will send your appeal to an independent review organization for consideration, as needed. A ruling will be mailed to you within 14 calendar days of accepting your appeal.

  • If we’re going to reduce or stop a service that you were getting, you can keep getting benefits during the appeal and state fair hearing process. The appeal must be filed within 10 days of the date the denial letter was mailed
  • You must ask to keep the service

The service will stop if:

  • You withdraw your appeal
  • You don’t ask for a state fair hearing within 10 days of getting the denial letter
  • A state fair hearing ruling is made against you

The authorization ends or service limits are met