External Medical Review (EMR)
The review process conducted by an independent, external medical review entity that is initiated by a provider who disagrees with a managed care organizations (MCO’s) decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity.
Providers who disagree with Buckeye Health Plan’s determination on a dispute to deny, limit, reduce, suspend, or terminate a covered service for lack of Medical Necessity or Level of Care may request an External Medical Review with Permedion.
Services denied, limited, reduced, suspended, or terminated for reasons other than lack of Medical Necessity or Level of Care and for which no clinical review was completed by Buckeye Health Plan are not subject to External Medical Review.
- The request for External Review must be submitted to Permedion within 30 calendar days of the written notification that the preservice appeal or provider Medical Necessity/Level of Care claim dispute process has been exhausted.
- Providers must complete the Ohio Medicaid MCE External Review Request form. Select Contract Information and Ohio Medicaid. Submit to Permedion together with the required supporting documentation including:
- Copies of all adverse decision letters from Buckeye Health Plan (initial and appeal).
- All medical records, statements (or letters) from the treating health care providers, or other information that the provider wants considered in reviewing of the case that were not previously submitted to the Buckeye Health Plan during its review process.
- Providers need to upload the request form and all supporting documentation to Permedion’s provider portal. New users will send their documentation through secured email at IMR@gainwelltechnologies.com to establish portal access.
- For more information on the External Medical Review, please contact Permedion at 800-473-0802, Option 2.
- The external medical review process:
- Is available at no cost to the provider.
- Does not interfere with the provider’s right to request a peer-to-peer review.
- Does not interfere with a member’s right to request an appeal or state hearing.
EMR is only available to providers for services delivered to members enrolled in Medicaid managed care and/or OhioRISE. The EMR process is not currently available in the MyCare Ohio or Single Pharmacy Benefit Manager (SPBM) programs.