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OhioBWC - Common - Form: (C-11) - Introduction
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ADR Appeal to the MCO Medical Treatment/Service Decision
(C-11)
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| Introduction |
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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.
Authorized users also may use this form to withdraw an appeal by completing the
Withdraw appeal section.
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| 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
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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
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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
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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
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| Complete the forms |
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Are you missing some of the required information? If so, you may return here
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this online form. Or, you may print a blank copy of the form to complete by
hand and either mail or fax it to BWC.
Print a blank form.
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