Questions Complaints Regarding Medicaid Behavioral Health 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the BASIC INFORMATION section. Enter the Provider Name, NPI, Address, Telephone Number, Provider Agency Name, and Program Type. Ensure all details are accurate for effective communication.
3. In the Primary Area of Inquiry field, specify your concern (e.g., claims, prior authorization). Provide a detailed description of your question or issue in the designated area.
4. If you have contacted another State Agency regarding this matter, include their contact information and summarize the outcome of that interaction.
5. If applicable, list any Managed Care Organizations (MCOs) involved in your issue. Indicate whether you participate in the plan’s network.
6. For claims-related issues, attach an encrypted spreadsheet with required details such as Member Client ID Numbers and claim statuses. Include outreach efforts to the Plan with dates and names of representatives contacted.
7. Review all entered information for accuracy before submitting via your chosen Field Office button at the bottom of the form.

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