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.