Providers should contact the associated managed care entity (MCE) for assistance before submitting a complaint (see hyperlink below) to the Ohio Department of Medicaid (ODM).
Providers should contact the MCE’s provider services line and/or their regional provider relations representative. Providers are encouraged to use the appeals, grievance, or arbitration processes as outlined in their individual contract with that MCE. If the MCE or MCE’s representative does not return a provider’s call within five business days, the provider may complete the provider complaint form below. Providers should also check the MCE’s Claims Payment Systemic Errors (CPSE) report for the issue in question.
All complaints submitted are sent immediately to the corresponding MCE for response. Please note the MCEs will have up to 15 business days to respond. ODM staff review each complaint received along with the MCE response in order to identify issues and trends. Please note that ODM does not follow-up with all providers on complaints submitted but the MCE will follow-up.
Submission Tips: Providers may add supporting documentation directly to the provider complaint form. Up to five attachments may be uploaded on a single complaint. To upload documents, you will need to select “Yes, involves specific member(s)” and then “Add attachment for patient information.” If multiple individuals are affected by a single issue with a plan, the provider is to submit only one complaint for all individuals. Individual information may be uploaded via attachments or manually. In the event there is a reoccurrence of a previously resolved complaint, providers should submit a new complaint, mark the question “Is this complaint related to any previously submitted complaints?” on the complaint form as yes, and enter the previous complaint’s number.
The provider inquiry form is located here. Ensure your pop-up blocker is turned off.
- External Medical Review (EMR) Provider Authorization Denial Grid
- External Medical Review Provider Journey Map
- External Medical Review (EMR) FAQ
- Medicaid Managed Care Benefits (by provider type)
- Next Generation of Ohio Medicaid Managed Care
- MyCare Ohio Payment Requirements
- MyCare Ohio Provider Payment Assistance
The Next Generation of Managed Care
Ohio Medicaid delivers health care coverage to more than 3 million Ohio residents. Of those, more than 90% receive coverage through one of five MCOs - Buckeye Health Plan, CareSource, Molina Healthcare, Paramount Advantage, or UnitedHealthCare Community Plan. Because managed care impacts such a large number of Ohioans, Ohio Medicaid has done a top-to-bottom review. Ohio Medicaid has embarked on a next generation managed care approach to align with today’s expectations for the future of health care.
Throughout 2021, Ohio Medicaid will work with incoming MCO to prepare for the beginning of services under the new program in January 2022. The hallmarks of Ohio's next generation Medicaid managed care program include:
- Improving wellness and health outcomes through a unified approach to population health that includes a new emphasis on defined principles to address health inequities and disparities.
- Emphasizing a personalized care experience through a seamless delivery system for members, providers, and system partners.
- Supporting providers in better patient care by reducing administrative burdens and promoting consistency.
- A centralized credentialing system eliminates the need to perform a unique credentialing process with each MCO.
- The fiscal intermediary serves as a central clearinghouse for provider claims and prior authorization requests.
- Improving care for children and adults with complex needs, including the establishment of OhioRISE, a comprehensive and coordinated behavioral health services approach for eligible children under the age of 21.
- OhioRISE is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child serving systems.
- Increasing program transparency and accountability through increased sharing and consistency of data across all entities involved in the Ohio Medicaid system and increased use of tools to monitor and oversee performance.
- Through a statewide Single Pharmacy Benefit Manager (SPBM), the next generation of managed care addresses a duplicative and opaque pharmacy benefit system that exists under the prior generation of managed care. Instead of each MCO managing a unique contractual relationship with one or more respective pharmacy benefit managers, the next generation approach gives the SPBM responsibility for providing and managing pharmacy benefits for all individuals enrolled in Ohio Medicaid managed care. The SPBM will be governed by a single set of clinical and prior authorization policies and claims process, and provide a standard point of contact, reducing the administrative burden on providers.
Each of these goals is also supported through the procurement of and transition to new MCO contracts.
We know you’re going to have questions
Ohio Medicaid’s new approach to managed care is based on extensive feedback we received from providers, Ohio Medicaid members, and other key stakeholders about the way the current system was working for them. We know that you face an increasingly complex set of requirements that can take valuable time and energy away from what you entered medicine to do: help people stay well.
While our new approach is designed to reduce administrative burden and make it easier to deliver a more personalized type of care, we know you’ll still have questions. Ohio Medicaid has established dedicated support to answer your questions. Visit the managedcare.medicaid.ohio.gov website for the latest information regarding Ohio’s next generation managed care program and initiatives, and feel free to send us a message at firstname.lastname@example.org.