Ask for a State Hearing

NOT FOR COUNTY USE

If your issue is about a managed care plan service denial, termination, reduction, or suspension, you must first appeal through your managed care plan. If you do not know your managed care plan phone number, please call the Ohio Medicaid Consumer Hotline for assistance at 1-800-324-8680.

You can ask for a state hearing, if you disagree with what we are doing or think we are making a mistake.  A hearing officer representing ODJFS and Medicaid will make a decision after the hearing.  If you want a hearing, we must receive your request 90 days from the date this notice was mailed to you.  If the 90th day falls on a holiday or weekend, the deadline will be the next work day.  If we receive your hearing request within 15 days of the notice mail date, your benefits or services will not be stopped or lowered until a hearing decision is issued.   To request a state hearing, please fill in the following information:

* Indicates Required Field

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Case Number:

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First Name:

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Last Name:

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Address:

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City:

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State:

(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

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Zip Code:

 

Phone Number with Area Code:

 

Email Address:

 

Agency that took the Action:

 

Notice Mail Date:

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Select all the programs that apply to this request: (select at least one)

If your program is not listed below, call us at 1-866-635-3748 or select OTHER and provide details in the description area.

Cash Assistance
Food Assistance
Medicaid
Medicaid Waiver
Prevention Retention and Contingency (PRC)
Child Care
Adoption Assistance
Child Support
Other
   

 The following information is OPTIONAL:

While you are awaiting your hearing, consider reapplying for assistance by visiting https://benefits.ohio.gov/.

On the Day of the State Hearing: You, or someone else helping you with your case, can explain the reason(s) why you don’t think the decision is right. An agency representative will explain the reasons. The hearing officer may limit the number of witnesses allowed in the hearing at any one time if there is not enough room. You and your representative will have the right to look at the evidence used at the hearing, present your side of the case without undue interference, ask questions, and bring papers or other evidence to support your case. The hearing will be recorded by the hearing officer so that the facts are taken down correctly. After the hearing decision is issued, you can get a free copy of the recording by contacting the Bureau of State Hearings. The hearing officer will listen to both sides but will not make a decision at the hearing. Instead, you will receive a written decision in the mail issued by the hearing authority.

You can ask your local Legal Aid program for free help with your case. Contact your local Legal Aid office by phoning 1-866-LAW-OHIO (1-866-529-6446) or by searching the Legal Aid directory at http://www.ohiolegalhelp.org/find-legal-help/.

By typing your electronic signature below, you are saying you are the person requesting the Bureau of State Hearings to process a state hearing request for you.

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Signed (type your full name):

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Date:

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