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Information for Providers Before Making a Complaint

Providers are responsible for confirming the Medicaid eligibility and the Managed Care Plan (MCP) insurance coverage—or plan enrollment—of a patient.

The Ohio Department of Medicaid has two sources for eligibility and enrollment information:

All providers must follow the grievance and appeal procedures outlined in their contracts with the Medicaid Managed Care or MyCare Ohio Plans.

The Ohio Department of Medicaid cannot intervene in contractual disputes between a provider and a Medicaid Managed Care or MyCare Ohio Plan.
Reimbursement Information

Medicaid Managed Care and MyCare Ohio Plans are not required to reimburse providers who are not contracted with that plan or who do not have a provider reimbursement agreement in place of a contract.  There are important, limited exceptions to this rule:

  • Transitional benefits are paid for services provided to newly enrolled members of a Medicaid managed care plan;
  • Transitional benefits are paid for services provided to newly enrolled members of a MyCare Ohio plan; and,
  • Providers must verify with the Medicaid Managed Care or MyCare Ohio Plan any such transitional benefits before rendering services.  These are not matters that involve the Ohio Department of Medicaid.
Providers who are not contracted with a Medicaid Managed Care or MyCare Ohio Plan but who are authorized under agreement with the Medicaid Managed Care or MyCare Ohio Plan to provide service to its members must ensure they have a written and mutually agreed compensation schedule prior to rendering service.
Patient Disenrollment

MyCare Ohio members and  Medicaid managed care members covered under the Adult Extension eligibility categories are qualified for long term care services in a nursing facility.

Therefore, members of these groups will not be subject to nursing facility disenrollment. Contact the MCP involved to report admission of a patient; to confirm the category of Ohio Medicaid provided; and to request authorization and payment for MyCare Ohio or Adult Extension Medicaid managed care members.


If you have read all of the above and would still like to make a complaint,
access the Provider Complaint Form
here.