Manuals, Forms and Reference Tools

Buckeye Health Plan Hospice HCIC and Vent/Vent Weaning Billing Guidelines

Information below applies to Medicaid and MyCare Ohio Network Providers

Effective 10/01/2021, Billing for Hospice HCIC and Vent/Vent Weaning will only be accepted on a Uniform Billing (UB) form. Claims submitted on a CMS 1500 form will be denied for incorrect billing.

The below guidance should be followed for both Hospice and Vent/Vent-Weaning billing. If not specifically noted below, all other fields should be billed according to the Uniform Billing Editor facility claim submission billing requirements.

UB-04 Box 80 – The name, address, telephone number and NPI of the nursing facility (NF) where the hospice room and board services are being performed must be included. If the required information is left blank, the claim will be denied for incorrect billing. Buckeye Health Plan will validate the service location to confirm it is a certified HCIC. If it is not a certified facility, the claim will be denied for incorrect billing.
Type of Bill – 81X/081X: If the claim is billed with the incorrect Type of Bill, the claim will deny as incorrect billing.
HCPCS Code: This field should be left blank. If information is present the claim will deny as incorrect billing. Facilities should not bill Hospice Room and Board code T2046 or any other HCPCS Code.

Hospice HCIC Specific Billing Requirement:

• Revenue Code: The below table labeled “ODM HCIC Nursing Facilities Per Diem rates” describes the revenue codes to bill based on the HCIC Service Level of the member. Claims billed with any other Revenue Codes will be denied as incorrect billing. Vent/Vent Weaning Specific Billing Requirement:

ODM HCIC Nursing Facilities Per Diem Rates
HCIC Service Level	COVID-19: Related Need	Flat Fee Daily Rate	Revenue Center Code
Quarantine Level of Care	Frequent Monitoring	$250	167
COVID-19 Level 1	Minor COVID-19: Related symptoms; frequent monitoring	$300	241
COVID-19 Level 2	Requires oxygen or other respiratory treatment and careful monitoring for signs of deterioration	$448	242
COVID-19 Level 3	Requires care beyond the capacity of a traditional NF	$820	243
COVID-19 Level 3 with ventilator	Requires care beyond the capacity of a traditional NF and ventilator care to support breathing	$984	249

Hospice Vent/Vent-Weaning Specific Billing Requirement:

Revenue Code: The below table labeled “Hospice Vent/Vent Weaning Nursing Facilities Per Diem Rates” outlines the revenue codes to bill based on the Vent/Vent Weaning Service Level of the member. Claims billed with any other Revenue Codes will be denied as incorrect billing. Please note that primary diagnosis code Z99.11 is required for the claim to be payable.

Hospice Vent/Vent Weaning Nursing Facilities Per Diem Rates
Vent/Vent Weaning Service Level	NF Specialty Code	Flat Fee Daily Rate 7/18/2020 – 6/30/2021	Flat Fee Daily Rate 7/1/2021	Primary Diagnosis Code	Revenue Center Code
Vent-dependent - full rate for meeting Ventilator-Associated Pneumonia (VAP) threshold	862	$819.49	$972.46	Z99.11	419
Vent weaning - full rate for meeting VAP threshold	867	$983.39	$1,166.95	Z99.11	410
Vent-dependent rate - 5% reduction for not meeting VAP threshold	864	$778.52	$923.84	Z99.11	419
Vent weaning - 5% reduction for not meeting VAP threshold	868	$934.22	$1,108.60	Z99.11	410

Nursing Facility Room and Board (T2046)

Buckeye Health Plan will continue to require nursing facility room and board hospice services to be billed using the HCFA (CMS-1500). The name of the nursing facility in which the services were delivered must be placed in Box 32 and the NPI related to the nursing facility must be placed in 32a.

Hospice NF RB Billing Guidance Highlights (PDF)

Electronic Deposit Forms

Add New Practitioners or Facilities to Existing Contracts

New Practitioner Enrollment Form (PDF)
New Provider Location Form (PDF)
Ohio Department of Insurance - New Facility Provider Request (PDF) (Medical Services Only)
Behavioral Health Facility Application (PDF) (Behavioral Health only or facilities that provide both Behavioral Health and Medical)
Standard Direct Practitioner Roster (Excel) (Direct Groups or facilities to use for submitting multiple practitioners)

Enrollments Must be Submitted with the Form Below:

Disclosure of Ownership and Control Interest Statements Form (PDF)

Non-Contracted Providers

If you are not contracted with Buckeye Health Plan or the group/facility you are with does not hold a contract with us, please go to the Join Our Network page.

Provider Update and Change Forms

Facility Agency Update and Change Forms

Facility Change Form (PDF)

Patient Liability Discrepancies

Patient Liability Discrepancy Form & Instructions (PDF)

Medicaid/General Forms

Medicare Forms

MyCare Forms

*JFS 03199 rev 04/2011 Must be used as of July 1, 2012

***Both versions 2010 and 2012 can be used as content remains unchanged.

Below are documents you will find helpful when working with on ADHD and depression issues with patients.

ADHD

Depression

InterQual criteria are available for your review upon request.

As a new requirement to ensure clinical consistency and coverage of Medicaid services across the full American Society of Addiction Medicine (ASAM) continuum, Buckeye must use The ASAM Criteria® in determining coverage for inpatient hospital services when the hospital provides the clinical documentation to support the review using ASAM Criteria®. Buckeye will continue to use Interqual clinical guidelines for determining inpatient hospital level of care that take into consideration all symptoms and clinical issues (SUD, psychiatric, and other medical conditions); however, for individuals with SUD conditions, Buckeye will also consider ASAM Criteria® prior to denying inpatient hospital services. When a hospital does not provide documentation to support the review using the ASAM Criteria® and the individual does not meet inpatient level of care using Interqual clinical guidelines, Buckeye will request additional documentation ASAM Criteria® for further consideration. Inpatient hospital services must be authorized if either of the following apply:

The request for admission or continued stay meets inpatient level of care criteria using Interqual clinical guidelines for hospital services, or:
The request for admission or continued stay meets ASAM level 4.0 or 3.7 criteria.

AS 4.0 Documentation Form (PDF)

Please click on the documents below for more information about new Medicaid Level of Care Rule Changes that became effective March 19, 2012.

Buckeye Health Plan has contracted exclusively with J&B Medical Supply and Edwards Health Care Services to provide our Medicaid and MyCare members with some of their medical supplies through a mail order program. They should be utilized for supplies listed in this notice (PDF).

Note: If a member has a different Primary Insurer and Buckeye as their Secondary Insurer, they may use any DME provider they choose for all of their supply needs.

These vendors provide high-quality, brand name products and helps our Buckeye members with product selection and education. They can often provide product samples to help find the most appropriate product to meet the member’s individual needs to achieve the best clinical outcome.

When writing the prescription, it is important to complete it in its entirety, including a valid primary and secondary ICD-10 diagnosis. You may also request blank prescription forms:

J&B Medical Supply: providerservices@jandbmedical.com
Edwards Health Care Services: contactus@myehcs.com

If you have any questions, please contact Provider Services at 1-866-296-8731.

2019

2020

2021

2022

Please use the Patient/Client Liability (PL) Reconciliation form below to report PL errors or discrepancies for claims paid by Buckeye Health Plan. It should be used in the following circumstances:

You identify a situation in which the plan deducted a PL amount from a payment that is more than the PL amount specified by the county or AAA caseworker.
You identify a situation in which the plan deducted no PL from a claim, but you have documentation that the member does have a PL amount.

Complete the fillable PDF form located below.

Note:

You must submit documentation of the correct PL amount (for example, a MITS screen shot).
You may need to resubmit the form for future claims involving the situations listed above if PL still is deducted incorrectly. You do not need to resubmit the supporting documentation if you submitted it once and it has not changed.
Please check the appropriate column on the form if you are resubmitting PL information for a Buckeye Health Plan MyCare member.

Please use the following email address to submit the form. To comply with HIPAA, you must use secure email. MyCareOHClaims@CENTENE.com Use Subject line: Patient Liability

Patient-Client Liability Reconciliation Form(PDF)

Ambulatory Surgical Center Codes (PDF)

Ohio Managed Care Plans

Consolidated Medicaid Plan Resource Guide (PDF)

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.

Manuals, Forms and Reference Tools

Quick Reference Guides

Hospice Billing Guidelines

Buckeye Health Plan Hospice HCIC and Vent/Vent Weaning Billing Guidelines

Manuals

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Electronic Deposit Forms

Add New Practitioners or Facilities to Existing Contracts

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Provider Update and Change Forms

Facility Agency Update and Change Forms

Patient Liability Discrepancies

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MyCare Forms

ADHD/Depression Toolkits

ADHD

Depression

InterQual

Provider Authorization for ASAM 4.0 W/M Level of Care (formally known as detox)

OAC Level of Care Rules

Pharmacy Resources

DME Suppliers

Claims Payment System Error Notifications (CPSE)