If You Have Problems With Your Health Plan
Appeals and grievances
If you are unhappy with AmeriHealth Caritas Ohio or our providers, or do not agree with a decision we made, contact us as soon as possible. You, or someone you want to speak for you, can contact us. If you want someone to speak for you, you will need to let us know. AmeriHealth Caritas Ohio wants to help.
To contact us, you can:
- Contact Member Services Department at 1-833-764-7700 (TTY 1-833-889-6446).
- Fill out the form in your member handbook.
- Call Member Services Department to ask for a printed copy.
- Write a letter telling us what you are unhappy about. Please include your first and last name, the number from the front of your AmeriHealth Caritas Ohio member ID card, your address and your telephone number. You should also send any information that helps explain your problem.
Mail the form or your letter to:
AmeriHealth Caritas Ohio
PO Box 7133
London, KY 40742
AmeriHealth Caritas Ohio will send you something in writing if we decide to:
- Deny a request to cover a service for you;
- Reduce, suspend, or stop services before you receive all of the services that were approved; or
- Deny payment for a service you received that is not covered by AmeriHealth Caritas Ohio.
We will also send you something in writing if we did not:
- Decide on whether to cover a service requested for you; or
- Give you an answer to something you told us you were unhappy about.
If you do not agree with the decision or action listed in the letter, you can contact us within 60 calendar days to ask that we change our decision or action. This is called an appeal. The 60- calendar day period begins on the day after the mailing date on the letter. If we have decided to reduce, suspend, or stop services before you receive all of the services that were approved, your letter will tell you how you can keep receiving the services if you choose and when you may have to pay for the services.
Unless we tell you a different date, we must give you an answer to your appeal in writing within 15 calendar days from the date you contacted us. If we do not change our decision or action because of your appeal, we will notify you of your right to request a state hearing. You may only request a state hearing after you have gone through the AmeriHealth Caritas Ohio appeal process.
If you contact us because you are unhappy with AmeriHealth Caritas Ohio or our providers, this is called a grievance. AmeriHealth Caritas Ohio will give you an answer to your grievance by phone, or by mail if we can’t reach you by phone. We will give you an answer within the following time frames:
- Two working days for grievances about not being able to get medical care
- Thirty calendar days for all other grievances except grievances about getting a bill for care you have received
- Sixty calendar days for grievances about getting a bill for care you have received.
If we need more time to make a decision for either an appeal or a grievance, we will send you a letter telling you that we need to take up to 14 more calendar days. That letter will also explain why we need more time. If you think we need more time to make a decision on your appeal or grievance, you can also ask us to take up to 14 calendar days.
You also have the right to file a complaint at any time by contacting:
- Ohio Department of Medicaid
Bureau of Managed Care Compliance and Oversight
PO Box 182709
Columbus, Ohio 43218-2709
1-800-605-3040 or 1-800-324-8680
- Ohio Department of Insurance
50 W. Town Street
3rd Floor, Suite 300
Columbus, Ohio 43215
If you are unhappy with the result of your appeal, you can ask for a state fair hearing.