MEDICAID PROVIDER ISSUE FORM Do not put protected health information in this form. Question Title * 1. Which MCO is the issue with? (Complete a separate form for each MCO.) Magnolia Molina United Healthcare OK Question Title * 2. What is/are the issues with the above selected MCO? Incorrect denial of claim or claim line(s) Incorrect denial of authorized service Code or modifier issue Medical necessity Incorrect rate payment Other or briefly expand above issues. OK Question Title * 3. Please enter the following contact information: Date(s) of service Provider Name Patient ID# OK DONE
