Select if you work for a third party billing agent. Select if you work for an individual Medicaid provider or group practice

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1 Basic Information Please provide your name and tell us if you are a third party Billing Agent or a Medicaid provider (or you work directly for a Medicaid Provider). Select if you work for a third party billing agent Select if you work for an individual Medicaid provider or group practice Enter your Medicaid billing agent ID number, not the rendering provider s ID number Enter the rendering Medicaid provider s primary specialty

2 Enter the Medicaid provider s ID or NPI number If the NPI is tied to multiple Medicaid provider ID numbers, the Medicaid provider ID is preferred. Enter the Medicaid provider s primary specialty Contact Information Please provide your contact information and best time of day to reach you.

3 Tell us about your issue - If your issue involves a Medicaid health or dental plan, select Health/Dental Plan from the drop down list. If your issue is related to the Fee-For-Service delivery system (i.e. straight Medicaid), select Medicaid Fee-For-Service from the drop down list. Please note the Agency reviews all submitted complaints, both plan and Fee-For-Service. Important: If your issue pertains to any errors, action taken/not taken, or information provided by a Medicaid Health or Dental Plan, you must select Health/Dental Plan. Failure to do so will delay the processing of your complaint. For Health/Dental Plan submissions: Select the option that best describes your issue from the list below. If your issue is related to claims payment, you must select I have submitted claims or am trying to submit claims and have not received proper or timely reimbursement. This includes disputes related to plan claims processing policies and procedures. Selecting any other option will delay the processing of your complaint.

4 For Medicaid Fee-For-Service submissions: Select the option that best describes your issue from the list below Proceed with answering the questions as prompted. When you reach the end of the questionnaire path, you are asked if you have any additional information to share. Please provide a brief summary of the issue in this text field. It is also helpful if you can list a couple of recipient Medicaid numbers related to the issue reported. Attaching supporting documents Tips We encourage you to submit a few samples of related EOBs; however, you do not need to attach every EOB related to the reported problem. Please DO NOT submit aging reports. Submitting an aging report can cause delays with processing your complaint. Any recipient detail attached must be related to the plan named in the complaint. Submitting recipient detail for another plan s enrollees or for non-medicaid members is a HIPAA violation. Reporting multiple issues Once you ve uploaded your supporting documents, you are asked if you have any other issues you d like to report. This could be: the same issue you just reported, but for a different plan an entirely new issue for the same plan an entirely new issue for a different plan Answering Yes will allow you to report an additional issue without having to reenter the basic or contact information.

5 Please do not report the same issue for the same plan. This creates a duplicate complaint and may cause delays with processing your original submission. This includes submitting the same issue, but for a newly impacted batch of claims. Submitting your issue(s) Once you have finished entering the issues you wish to report, you are provided the option to review and make any corrections prior to submitting. If the information appears correct, you must select Finish to submit your issue(s). Once you submit, you will receive a complaint tracking ID. It is important to retain this number so you may check the status of your complaint(s).