File a Grievance or Appeal
As a Ë¿¹Ï¶ÌÊÓƵ 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:
- Phone: Call Member Services at 1-855-475-3163 (TTY: 1-833-711-4711 or 711). We are open 8 a.m. to 8 p.m., Monday – Friday.
- Online: Fill out the Coverage Determination Request Form online.
- Fax: 1-855-489-3403
- Mail: Download the Coverage Determination Request Form and mail it to
Express Scripts,
c/o Medicare Clinical Appeals,
P.O. Box 66588
St. Louis, MO 63166-6588.
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:
- Phone: Call Member Services at 1-855-475-3163 (TTY: 1-833-711-4711 or 711). We are open 8 a.m. to 8 p.m., Monday – Friday.
- Online: Fill out the Coverage Determination Request Form online.
- Fax: 1-844-417-6157
- Mail: Download the Coverage Determination Request Form and mail it to
Ë¿¹Ï¶ÌÊÓƵ,
P.O. Box 1307
Dayton, OH 45401-1307
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 Ë¿¹Ï¶ÌÊÓƵ 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 Ë¿¹Ï¶ÌÊÓƵ 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 Ë¿¹Ï¶ÌÊÓƵ MyCare Ohio to talk with your appointed representative, must fill out the . 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.