Provider Complaint Form

OH Medicaid Managed Care Provider Complaint Form

Instructions

This form is for Managed Care providers only. Providers must challenge the decision of all denied claims and prior authorizations with the Managed Care Organization (MCO) using the appropriate processes (appeal, dispute, etc.) before the Ohio Department of Medicaid will process a complaint. If your complaint involves multiple MCOs, please complete one form per MCO. The resolution time frame for Managed Care complaints is 15 business days. If you have a complaint regarding Medicaid Fee For Service please call 1-800-686-1516.

Complaint Details

Which Program is this complaint related to? Medicaid MyCare OhioRISE SPBM *
MCO Name:		Health Plan is required *
Complaint Reason:		*

		* Is this complaint related to any previously submitted complaints? Yes No

Please summarize your complaint in the text box below: required


Please describe actions already taken to resolve issue with MCO. Include names of representatives, prior contact dates, relevant claim #’s, expected resolutions, etc.: required

Date Appeal was denied.	Appeal #	MCO Call Reference #
Does this issue impact specific member(s)?	No, doesn’t involve specific member(s) Yes, involves specific member(s)

Provider/Follow-up Details

Provider Name:	*	Follow-up Name:	*
Follow-up Type:	Phone/EmailMail

Phone:	* Invalid Phone Ext:	Email:	* Invalid Email
Fax:	Invalid Fax

MCO Provider #:
Medicaid Provider Number (MPN):	*	Tax ID #:	*
County:	*
Provider Type:	*


Enter the number shown in the image above. * Indicates a required field


Click button once to submit complaint. Do not submit multiple copies of same complaint. We will send a confirmation message with tracking# to your email (if supplied on this form).