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OhioBWC - Common - Form:  (C-11) - Introduction

ADR Appeal to the MCO Medical Treatment/Service Decision
(C-11)
Introduction

Injured workers, employers, medical providers or authorized representatives should use this form to appeal the managed care organization's (MCO's) medical treatment/service decision. This form initiates the alternative dispute resolution (ADR) process.
Note: Authorized users also may use this form to withdraw an appeal by completing the Withdraw appeal section.


Required information
Injured worker
  • Claim number
  • Name
  • Phone number
  • Date of MCO initial decision letter
  • Date of receipt of MCO initial decision
  • Whether treatment/service was denied, approved or amended
  • Specific explanation of what is being appealed
  • Reason for appeal
Employer
  • Claim number
  • Injured worker name
  • Employer name
  • Contact person
  • Contact phone number
  • Date of MCO initial decision letter
  • Date of receipt of MCO initial decision
  • Whether treatment/service was denied, approved or amended
  • Specific explanation of what is being appealed
  • Reason for appeal
Injured worker/Employer representative
  • Claim number
  • Injured worker name
  • Representative name
  • Representative ID number
  • Phone number
  • Date of MCO initial decision letter
  • Date of receipt of MCO initial decision
  • Whether treatment/service was denied, approved or amended
  • Specific explanation of what is being appealed
  • Reason for appeal
Medical provider
  • Claim number
  • Injured worker name
  • Provider name
  • Specialty
  • Phone number
  • Date of MCO initial decision letter
  • Date of receipt of MCO initial decision
  • Whether treatment/service was denied, approved or amended
  • Specific explanation of what is being appealed
  • Reason for appeal

Complete the forms

If you have all the required information on hand, simply click the start button to begin.

Start

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