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Post Service Provider Disputes-Appeals

To check the status of previously submitted claim(s), providers should contact the Buckeye Provider Services Department at 866-296-8731, Monday through Friday 7:00 a.m. – 8:00 p.m. Providers can also check claims status on our portal by accessing the Provider Home Page. 

Providers should have:

  • servicing provider’s name
  • member name
  • member ID number
  • date of birth
  • date of service
  • claim number

Buckeye offers providers the option to request payment evaluation/and or determination of a previously submitted claim(s) by means of a claims dispute.

Provider claim disputes/appeals are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim payment or denial. While these disputes can come in through any avenue (e.g., provider call center, provider advocates, BHP’s provider portal), they do not include inquiries that come through ODM's Provider Web Portal (HealthTrack).

To submit a claim dispute, there must have already been a first-time claim submitted that has been paid or denied accordingly. If a claim has not been submitted, the claim does not qualify for a claim dispute.

Effective February 1, 2023, the provider dispute process for Ohio Medicaid and Behavioral Health has changed. It impacts timely guidelines, submission methods, and provider notifications.

Below are the different processes based on your claim's Date of Service.

Claim with a Date of Service prior to February 1, 2023

Provider disagreements with a previously paid or denied claim are split between a Provider Disagreement/Dispute or an Appeal.

  • A provider disagreement/dispute is any claim the provider disagrees with the previous claims outcome and the provider would like additional review performed on the claim. This excludes anything that requires review for Medical Necessity & Level of Care.

  • A provider appeal is any claim that requires Medical Necessity or Level of Care clinical review.
    • Claims requiring review for Medical Necessity/Level of Care will need to complete  the Prov Claim Dispute MedNec Review Form and Steps Pre 020123 form and include additional documentation required for clinical review attached to the provider appeal.
    • Provider is allowed 365 days from the date of service or 60 days from date of Explanation of Payment, whichever is later, to submit a claim appeal.
    • Once submitted, the claim will be reviewed and previous outcome either upheld or overturned and a new EOP sent to the provider.

Claim with a Date of Service on or after February 1, 2023

  • Provider disagreements with a previously paid or denied claim are now all considered a dispute, regardless of it being for Medical Necessity/Level of Care or not. For the fastest turnaround times and greater ability to track the status and receipt of the dispute, please submit utilizing one of the following options.

The new dispute process for claims with DOS February 1, 2023 and forward:

  • Allows providers to file a claim dispute no later than 12 months from the date of service or 60 calendar days after the payment, denial, or partial denial of a timely claim submission, whichever is later.
  • Allows providers to submit claim disputes verbally and in writing. This includes any disputes submitted through the provider portal, mail center, call center.
    • For the fastest turnaround times, please submit disputes via the Provider Web Portal.
  • Makes available to the provider the Provider Web Portal where they can confirm the receipt of their dispute, date received, claims data including member and provider data, previous claim outcomes and status of the claim and any associated claim disputes. 

Buckeye will thoroughly investigate each provider claim dispute using applicable statutory, regulatory, and contractual provisions, collecting all pertinent facts from all parties, and applying BHP’s written policies and procedures.

Buckeye will provide written notice to the provider of the disposition of all claim disputes once a resolution has been determined. Written notice will not be sent if the claim dispute was resolved with an initial phone call or in-person contact. Once a resolution has been determined for each claim dispute, Buckeye will reprocess and uphold or pay the associated claim as needed within 30 days from written notice of resolution.

To check the status of previously submitted claim(s), providers should contact the Buckeye Provider Services Department at 866-296-8731, Monday through Friday 7:00 AM – 8:00 PM Providers can also check claims status on our portal via our Provider Home Page. 

NOTE: Claim Disputes do not include new or corrected billing claims. New or corrected claims can be submitted via ODM’s FI/OMES system, provider web portal through the claim submission button or paper submissions to the address below.

Medicaid:
Buckeye Health Plan
P.O. Box 6200
Farmington, MO 63640-3800

Behavioral Health:
Buckeye Health Plan
P.O. Box 6150
Farmington, MO 63640-3800