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Manuals, Forms and Reference Tools

Electronic Deposit Forms

Add New Practitioners or Facilities to Existing Contracts

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.

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:

  1. The request for admission or continued stay meets inpatient level of care criteria using Interqual clinical guidelines for hospital services, or:
  2. 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 with J&B Medical Supply as the single-source vendor to provide our Medicaid & MyCare members with some of their medical supplies through a mail order program. Only J&B Medical Supply should be utilized for Buckeye Health Plan Medicaid members after March 1st, 2019 and MyCare members after April 1st, 2019 that need 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.

J&B provides 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.

How does this affect you?

Affected Buckeye Health Plan members will be contacted to begin the transition to J&B Medical. Once J&B establishes an account with your Buckeye Health Plan patients to discuss their medical needs related to covered supplies, J&B will send you an easy to complete prescription form. It is important to complete the prescription in its entirety, including a valid primary and secondary ICD-10 diagnosis. You may also request blank prescription forms from J&B by emailing your request to Once J&B has received the completed prescription, they will send a 30 day supply right to your patient’s door in discreet packaging.

Buckeye Health Plan and J&B are excited about the opportunity to work with you and your patients to provide high quality service and medical care. If you have any questions, please contact Provider Services at 1-866-296-8731.

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.


  • 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.  Use Subject line: Patient Liability

Patient-Client Liability Reconciliation Form(PDF)



Ohio Managed Care Plans

Consolidated Medicaid Plan Resource Guide (PDF)

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.