When an Ohio managed care organization (MCO) denies, approves or amends a requested treatment, such as a service on a C-9, the injured worker, employer, their representatives or the provider can appeal on this form. Filing it starts the alternative dispute resolution (ADR) process with the MCO. The appeal must reach the MCO within 14 days of receiving the written notice of its initial decision.
Whoever appeals completes the form and checks the matching 'Appealed by' block; a provider enters name, specialty and contact details and gives the reason for the appeal. The injured worker's name and BWC claim number are mandatory on every C-11.
Download the current version from the source each time; forms change without notice.
ADR Appeal to the MCO Medical Treatment/Service Decision
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. The C-11 lists the injured worker, the employer, their authorized representatives and the provider as parties who may appeal an MCO medical treatment or service decision. The provider completes the provider block under 'Appealed by', explains the reason for appeal and signs as the party filing it.
The appeal must be filed with the MCO within 14 days of receipt of the written notice of the MCO's initial medical treatment or service decision. The form asks for both the decision letter date and the date it was received, so keep a record of when the notice arrived.