CareSource Ohio, Inc. claim denials in Ohio: the federal figures
CareSource Ohio, Inc. denied 19.9% of in-network claims in Ohio — 444,660 claims out of 2,238,460. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to CareSource Ohio, Inc.) | 533 | 42.6% |
| External review (independent) | 25 | — |
What CareSource Ohio, Inc. denies most
The most common denial reason recorded for CareSource Ohio, Inc. plans in Ohio is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 251,796 | 49.5% |
| Service excluded from the plan | 85,111 | 16.7% |
| Provider out of network | 67,807 | 13.3% |
| Referral required | 52,809 | 10.4% |
| Member not covered | 24,855 | 4.9% |
| Benefit limit reached | 14,759 | 2.9% |
| Administrative reason | 11,115 | 2.2% |
What to do if CareSource Ohio, Inc. denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. CareSource Ohio, Inc. overturned 42.6% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not CareSource Ohio, Inc.. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your CareSource Ohio, Inc. appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is CareSource Ohio, Inc.'s denial rate high?
19.9% against a national average of 16% across the plans in this dataset. It is above average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can CareSource Ohio, Inc. ignore the external decision?
No. External review decisions are binding on the plan.