File a Grievance or Appeal

As a CareSource member, you have the right to submit a:

  • Coverage Determination – A decision we make about your benefits and coverage or the amount we will pay for your medical services, items, or medications.
  • Organization Determination – A decision we make about the coverage of a service.
  • Appeal – A request to have us reconsider and change the decision made or the action taken.
  • Grievance – An official complaint. This process is used for certain types of problems such as quality of care, waiting times, receiving a bill and customer service.

How to Request a Coverage Determination

To request a decision, you have these options:

Providers can complete the Coverage Determination Request Form to provide supporting statements for an exception request.

How to Request an Organization Determination 

To request a decision, you have these options:

If you are unhappy with our decision, you can appeal the decision by asking for us to reconsider the original request.

Find more information in chapter 9 of your Member Handbook on the Plan Documents page.

What is a State Hearing?

If your request for a covered service is not approved, you may be able to ask the state to review our decision. This is called a state hearing. Before any state hearing request, you must have followed the CareSource appeal process. If your appeal is denied and you qualify for a state hearing you will receive a request form with the letter we send you.*

*Once your appeal has been completed, if you disagree with the outcome and your decision letter included a state hearing request form, you may request a state hearing to have your request reconsidered.

Next Steps

Here’s more information about what to do next:

Plan Complaints

You can find out how many people have filed complaints against CareSource MyCare Ohio. Call Member Services and ask about “the total number of grievances, appeals and exceptions” for the Plan/Part D sponsor.

Call Member Services at 1-855-475-3163 (TTY: 1-833-711-4711 or 711), Monday – Friday, 8 a.m. – 8 p.m.

What is an Appointed Representative?

You can have a relative, friend, advocate, provider or other person who can act on your behalf in filing a grievance, coverage determination or appeal. We call these people appointed representatives.

In order for CareSource MyCare Ohio to talk with your appointed representative, must fill out the Appointment of Representative Form. Call Member Services to have the form mailed to you. This form must be sent each time you have someone submit a grievance, appeal or request for a decision on your behalf.