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Resource pages currently cover Kentucky and Indiana.

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This directory is under active review and may be incomplete. Confirm urgent details directly; No One Left Outside does not guarantee eligibility, availability, funding, acceptance, or placement.

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Kentucky Medicaid Managed Care Organization Dispute Form

Official owner Kentucky Cabinet for Health and Family Services

DMS escalation after using the member/provider MCO grievance or appeal process; requires tracking information.

What problem this helps solve

DMS escalation after using the member/provider MCO grievance or appeal process; requires tracking information.

Who completes it: Member/provider or properly authorized helper. The form asks for both provider and member information; askDMS how to handle unavailable fields.

What this does not prove

Follow the person's time-sensitive MCO appeal notice. Confirm the currently accepted DMS packet before use; this public copy does not replace the initial MCO appeal process.

Dated source check

Official destination opened — currentness caution

The retrieved five-page PDF prints Rev 09/25/2025. A different revised-PDF link on the maintained page returned 404. The public copy lists discontinued Anthem; the maintained plan list controls. The currently accepted packet remains UNKNOWN.

Last checked Sep 30, 2026. A working link does not establish the current edition, suitability, agency acceptance, or service availability.

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Direct document

Before downloading, confirm the agency, form number, and revision date match the summary below.

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Use the official pathway

NOLO's preparation notes summarize the dated sources in this record. Follow the agency's official instructions and current edition when they differ.

1. Check that this route fits

Stage and purpose
DMS dispute escalation after MCO process
Who completes it
Member/provider or properly authorized helper. The form asks for both provider and member information; askDMS how to handle unavailable fields.
Jurisdiction
Kentucky
Application mode
Print/mail; Email; Fax

2. Prepare before starting

  • Use own MCO grievance/appeal process first.
  • Obtain assigned ticket/tracking number; missing number prevents review.
  • Timing/notice rights and exceptions require agency guidance.

Documents named by the source

  • MCO assigned tracking number and dates/results of internal grievance/appeal.
  • Issue-specific supporting correspondence, claim/EOB/authorization records; claim template for multiple related provider claims.
Fees and fee waivers
UNKNOWN — no form fee stated.
Account
No account requirement stated for paper/email/fax.
Appointment
UNKNOWN — ask MCO/DMS for assistance.
Signature
Signer certifies truth and signs/dates dispute.
Third-party certification or assessment
Unknown — confirm any certification, referral, or assessment with the official owner.

3. Follow official submission instructions

Read official instructions
  • Mail DMS Division of Health Plan Oversight,Contract Monitoring Branch,275 E Main Street6E-D,FrankfortKY40621
  • Email —ProviderMCOInquiry@ky.gov
  • Fax —502-564-0223; AttentionContract Monitoring Branch

4. Get help or an accommodation

Languages: English source read; other versions UNKNOWN.

Accessibility: External source conformance was not evaluated; request agency assistance for an inaccessible process.

5. Know the supported next step

  • DMS form describes acknowledgment and follow-up; retain submission/tracking evidence.

Restrictions and unresolved details

  • Does not replace the person's time-sensitive MCO appeal notice.
  • Member disputes and provider payment appeals have different facts and rights.
  • Do not choose a discontinued plan based on old PDF choices.
  • Form requires provider/member fields; alternatives for a member without provider details remain UNKNOWN.
  • The maintained page's other revised-PDF link was unavailable. The retrieved copy's printed Rev 09/25/2025 is known, but present-day acceptance and unavailable member/provider-field alternatives remain UNKNOWN.

Follow the person's time-sensitive MCO appeal notice. Confirm the currently accepted DMS packet before use; this public copy does not replace the initial MCO appeal process.

PDF filling support

Print-only PDF (no interactive fields found). Checked 2026-10-05. Signature support and agency acceptance still need confirmation.

Continue with your journey

Return to the connected step to decide what to do next. Opening this record does not complete that step or submit an application. If the official route is unavailable, use the assistance options above or browse help in the journey.

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Form record

Adds to a private plan in this browser tab. Nothing is sent to the provider, and nothing is applied for.

Official title
Kentucky Medicaid Managed Care Organization Dispute Form
Form number
MCO Dispute Form
Program
Medicaid MCO dispute resolution
Jurisdiction
Kentucky
Revision / edition
Sep 25, 2025
Who completes it
Member/provider or properly authorized helper. The form asks for both provider and member information; askDMS how to handle unavailable fields.
Signature
Signer certifies truth and signs/dates dispute.
Submission methods
Mail DMS Division of Health Plan Oversight,Contract Monitoring Branch,275 E Main Street6E-D,FrankfortKY40621, Email —ProviderMCOInquiry@ky.gov, Fax —502-564-0223; AttentionContract Monitoring Branch
Supporting documents
  • • MCO assigned tracking number and dates/results of internal grievance/appeal.
  • • Issue-specific supporting correspondence, claim/EOB/authorization records; claim template for multiple related provider claims.
Languages
English source read; other versions UNKNOWN.
Accessibility
External source conformance was not evaluated; request agency assistance for an inaccessible process.

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Source note: Follow the person's time-sensitive MCO appeal notice. Confirm the currently accepted DMS packet before use; this public copy does not replace the initial MCO appeal process.

NOLO does not process this form, receive your answers, decide eligibility, or represent the agency. A destination check does not confirm current funding, acceptance, or an outcome.

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