Prior Authorizations

The process of getting prior approval from Buckeye as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage. Your doctor will submit a prior authorization request to Buckeye to get certain services approved for them to be covered.

Pre-scheduled, optional services must be approved by Buckeye before you are admitted. Your Provider will send a request to Buckeye.

  • Scheduled Acute Inpatient Hospital
  • Nursing facility services for a short-term rehabilitative stay
  • Long Term Acute Care Hospital (LTAC)
  • Skilled Nursing Facility
  • Hospice care (care for terminally ill, for example, cancer patients)

Requests for services from a Provider, facility, or vendor that is not in the Buckeye network need to be approved. In case of emergency, you should get medical care right away and then you or the doctor should call Buckeye as soon as possible.

Durable medical equipment (rental or purchase) over $500*

Prosthetics and orthotics over $250*

Please check the prescreening tool on the provider website to determine if prior authorization is required.

*Threshold based upon reimbursement in current Ohio Medicaid Fee Schedule

Any experimental or investigative procedure, service or drug protocol

Genetic testing requires prior authorization

  • Cardiac Rehabilitation –no prior authorization is needed for participating providers in an outpatient setting
  • Developmental therapy services for children aged birth to six years
  • Outpatient Physical, Occupational and Speech therapy starting with the 13th visit/re-evaluation based on a calendar year (January to December)
  • Home Health Care
  • Pain Management Services
  • Sleep study
  • Transplant evaluation services

Injectables greater than $250 given in an outpatient setting. See the Preferred Drug List for more information.

Quantitative Drug Testing for Drugs of Abuse requires prior authorization

  • MRIs
  • MRAs
  • PET Scans
  • CAT Scans
  • Nuclear cardiology
  • Stress Echocardiography
  • Echocardiography
  • OB ultrasounds > 3 per pregnancy
  • Oral Surgeon
  • Plastic and reconstructive surgeons
  • Abortion
  • Bariatric Surgery (Weight loss)
  • Blepharoplasty (Eyelid plastic surgery)
  • Cosmetic/Plastic surgery
  • Dental/Oral procedures
  • Hysterectomy
  • Implantable devices including Cochlear Implant
  • Mammoplasty (Breast augmentation surgery)
  • Otoplasty (Ear plastic surgery)
  • Rhinoplasty or Septoplasty (Nose plastic surgery)
  • Scar Revision
  • Treatment of Varicose Veins
  • Vagus Nerve Stimulation
  • Air Transport – fixed wing
  • Non-emergent ambulance (transfer from home to physician office when a patient is unable to go by other means)

Referrals

The process of your PCP recommending or requesting services for you before you can get them. Your PCP will call and arrange these services for you; give you written approval to take with you when you get the referred services; or just tell you what to do. In some cases, Buckeye may authorize a specialist to make referrals for you.

Your doctor might want you or your child to see a special doctor (specialist) for certain health care needs. While you or your child’s doctor can take care of most of your health care needs, sometimes they will want you or your child to see a specialist for your care. A specialist is a doctor who provides services for a particular kind of health service such as a podiatrist (foot doctor) or cardiologist (heart doctor).

Some specialist referrals from your or your child’s doctor may need approval from Buckeye to make sure the specialist is a Buckeye specialist, and the visit to the specialist or the specialty procedure is needed. In these cases, the doctor must first call Buckeye. If you or your doctor are not sure what specialty services need approval, Buckeye can give you that information. Buckeye will review the request for specialty services and respond with a decision.

Self-referred services are services that you may access without permission from your Primary Care Provider or from Buckeye. You may self-refer to a Buckeye provider for the following services:

  • Obstetrical (OB) and/or gynecological services, including:
  • Maternity care for prenatal and postpartum, including at-risk pregnancy services
  • Preventive mammogram (breast) and cervical cancer (pap tests) exams
  • Chiropractor
  • Podiatry (Foot) Care Certified Nurse Midwife
  • Routine Dental Care
  • Routine Vision (Optical) Services, including eyeglasses
  • Certified Nurse Practitioner
  • Urgent Care Centers Specialist services
  • Regular X-rays and lab (participating specialists may also send you for diagnostic tests) Outpatient hospital services (some surgical procedures may require prior authorization)
  • Clinic services Health education
  • Services for children with medical handicaps (Title V)
  • Renal dialysis (kidney disease)

You have the right to a second opinion from a qualified Buckeye provider on Buckeye’s panel. If a qualified provider is not able to see you, Buckeye must set up a visit with a provider not on our panel.