OH Medicaid Managed Care Provider Complaint Form

Instructions

This form is for Managed Care providers only. Providers must appeal denied claims to the MCP before the Ohio Department of Medicaid will process a complaint. If your complaint involves multiple Managed Care Plans (MCPs), please complete one form per MCP. The resolution timeframes for Managed Care complaints are 2 business days for complaints involving access to care, and 15 business days for all other issues. If you have a complaint regarding Medicaid Fee For Service please call 1-800-686-1516.

Complaint Details

MCP Name: *
Complaint Reason: *
* Are you contracted with this Health Plan?
* Is this complaint related to the MyCare Program?
* Have you already contacted the MCP about this issue?
* Is this complaint related to any previously submitted complaints?
* Is this complaint related to children with special health care needs?
* Is the patient receiving or seeking mental health or substance abuse services?
Please summarize your complaint in the text box below: required  

HIPAA Guidelines for Provider Complaint Attachments


Your submission must only include information for Medicaid members. Including personal information for non-Medicaid members is a HIPAA violation. If your attachment is found to include non- Medicaid enrollees, your entire complaint may be summarily rejected, and you may be asked to resubmit your complaint with the corrected detail.


If your complaint pertains to multiple Medicaid Plans, you must submit a separate attachment for each Plan. Each attachment must include only Medicaid enrollees pertaining to that Plan.

  • Click “Choose File” to select a single file from your computer

  • To select a different file click “Choose File” again

  • Click “Add” to attach a selected file to the complaint

  • To remove the file after "adding" to list, select file from the list, then click “Remove”

  • Each file must be 10MB or less in size & in following formats only: .pdf, .jpg, .png, .xls, .xlsx

  • Files Limit: Maximum of 5 files per complaint

If related to denied claims, Providers must appeal denied claims to MCP before ODM will process a complaint.
Date Appeal was denied.
Does complaint involve specific patients/consumers?

Provider/Follow-up Details

Provider Name: *   Follow-up Name: *  
Follow-up Type:
Phone: * Ext:  Email: *  
Fax:
Medicaid Provider Grp #: MCP Provider #:
Indiv Medicaid Provider (MPN) #: Tax ID #: *  
County: *   Provider Category: *  
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).