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Provider Alerts

When we receive urgent or critical information that can't wait for our newsletter delivery, we send you a Provider Alert. 

 

Ensuring members receive care is the Ohio Department of Medicaid’s priority. To verify if an individual is enrolled in a Next Generation MyCare plan, you can take the following actions:

  1. Check the Member ID Card. If the ID card has a Next Generation MyCare program logo it is indicative that the member is a Next Generation MyCare member.
  2. Check member eligibility via Provider Network Management (PNM) or the Electronic Data Interchange (EDI) 270/271 process.

If after completing these steps you encounter issues verifying a member’s enrollment, we encourage you to provide the member services and follow existing billing guidance at https://medicaid.ohio.gov/resources-for-providers/billing/billing. If you have questions or need help, call the ODM Integrated Helpdesk at 800-686-1516 or IHD@medicaid.ohio.gov. Representatives are available Monday through Friday, 8 a.m. – 4:30 p.m. Eastern Time.

Buckeye Health Plan is pausing the implementation of our new behavioral health policies (OH.UM.04, OH.UM.06, OH.UM.07. OH.UM.09) until the Ohio Department of Medicaid (ODM) completes the American Rescue Plan Act (ARPA) reconciliation process, which may take up to 60 days. The services address utilization thresholds for community-based services and intensive outpatient treatment.  The new policies are expected to remain unchanged and will be implemented as planned once the terms of ARPA are no longer applicable.   

Aligning with OAC 5160-26-03.1, Buckeye Health Plan must have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member.  As such, Buckeye must ensure services delivered to members are medically necessary, so these services will continue to be subject to retrospective utilization review.

To support providers in preparing for these upcoming policies, we will host a series of provider webinars in mid-January to review:

  • Prior authorization thresholds
  • Submission of prior authorization requests
  • Appeals and denial processes
  • Necessary clinical documentation
  • Tracking services through Buckeye’s provider portal

These webinars are designed to ensure a smooth transition once the policies are officially effective. We appreciate your understanding and continued partnership.

For more questions related to this update, please contact Provider Services or your assigned provider engagement representative.