Manuals, Forms and Reference Tools
- MyCare Ohio Quick Reference Guide (PDF)
- Completing a Well Visit During a Sick Visit (PDF)
- Provider DME Letter May 2019 (PDF)
- Prior Authorization Request Letter May 2019 (PDF)
- Durable Medical Equipment (DME) Provider Contact List for BP Monitors (PDF)
- Buckeye Products Overview & ID Card Reference Sheet (PDF)
- Member Rights & Responsibilities (PDF)
- Medicare Provider Toolkit (PDF)
- Qualified Medicare Beneficiaries (QBM) Billing FAQ (PDF)
- Healthchek Provider Reference Manual (PDF)
- EAPG 2017 Covered Codes (XLS)
- EAPG 2018 Covered Codes (PDF)
- BH Toolkit (PDF)
- Claims Submission Guide 2017 (PDF)
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:
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.
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 |
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.
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
- Address Change
- Demographic Change
- Update Member Assignment
- Term Practitioner
- Change NPI or IRS Information
Facility Agency Update and Change Forms
Patient Liability Discrepancies
Patient Liability Discrepancy Form & Instructions (PDF)
Medicaid/General Forms
- 30-Day Readmission Payment Policy (PDF)
- Abortion Certification Form (PDF)
- Advance Directives Form (PDF)
- Care Management Referral Form- Southwest Region (PDF)
- Care Management Referral Form- Northwest Region (PDF)
- Care Management Referral Form- Northeast Region (PDF)
- Care Management Referral Form- East Central Region (PDF)
- COB Dispute & Adjustment Request Form (PDF)
- Connections Referral Form (PDF)
- Acknowledgement of Hysterectomy Form rev 06-2021 (PDF)
- Consent to Sterilization - English - 2025 (PDF)
- Consent to Sterilization - Spanish - 2025 (PDF)
- Home Health Nurse & Aide Service Rate Change (PDF)
- Immunization Coding & Billing Guidelines (PDF)
- Medicaid Inpatient Prior Authorization Form (PDF)
- Medicaid Biopharmacy Outpatient Prior Authorization Form (PDF)
- Medicaid Outpatient Prior Authorization Form (PDF)
- OAHP PA Home Health Form (PDF)
- OAHP PA Nursing Facility Form (PDF)
- OAHP PA Standardized Form–Medicaid (PDF)
- Pain Management Referral Form (PDF)
- See Post Service Provider Appeals page
- Provider Claim Dispute Portal Instructions
- Request to Change PCP Form (PDF)
- Substance Use Disorder (SUD) Review Template (PDF)
- Waiver Services Prior Authorization Request (PDF)
Medicare Forms
- Provider Adjustment Request Form (PDF)
- Medicare Appeal Waiver of Liability Form (PDF)
- Medicare IV Home Request Process Form (PDF)
- Medicare Coverage-Determination Request Form (PDF)
- Medicare Inpatient Authorization Form (PDF)
- Medicare Outpatient Authorization Form (PDF)
MyCare Forms
- MyCare Inpatient Authorization Form (PDF)
- MyCare Outpatient Authorization Form (PDF)
- MyCare Coverage-Determination Request Form (PDF)
Behavioral Health Forms
- Ohio Uniform Prior Authorization Form - Community Behavioral Health Services (PDF)
- Applied Behavioral Analysis (ABA) for Autism - Authorization Form (PDF)
- Electroconvulsive Therapy (ECT) Form - Medicaid (PDF)
- Electroconvulsive Therapy (ECT) Form - Medicare (PDF)
- Outpatient Treatment Request Form - Medicare (PDF)
- Applied Behavior Analysis Covered Services (PDF)
- Substance Use Disorder Treatment Planning Guide (PDF)
- Medicaid Substance Use Disorder Prior Authorization Form (PDF)
- Medicaid Substance Use Disorder Residential Treatment Notification Form (PDF)
*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 and Depression Toolkit Introduction Letter (PDF)
- Behavioral Health & Wellness Brochure (PDF)
- Talking to Friends & Family Brochure (PDF)
- Suicide Prevention Brochure (PDF)
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.
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.
2023
- January 2023 - Updates of Reported CPSE Issues - January 15, 2023 (PDF)
- March 2023 - Updates of Reported CPSE Issues - March 15, 2023 (PDF)
- April 2023 - Updates of Reported CPSE Issues - April 15, 2023 (PDF)
- May 2023 - Updates of Reported CPSE Issues - May 15, 2023 (PDF)
- June 2023 - Updates of Reported CPSE Issues - Juine 15, 2023 (PDF)
- July 2023 - Updates of Reported CPSE Issues - July 15, 2023 (PDF)
- August 2023 - Updates of Reported CPSE Issues - August 15, 2023 (PDF)
- September 2023 - Updates of Reported CPSE Issues - September 2023 (PDF)
2022
- January 2022 - Updates of Reported CPSE Issues - January 18, 2022 (PDF)
- March 2022 - Updates of Reported CPSE Issues - March 15, 2022 (PDF)
- May 2022 - Updates of Reported CPSE Issues - May 15, 2022 (PDF)
- July 2022 - Updates of Reported CPSE Issues - July 15, 2022 (PDF)
- September 2022 - Updates of Reported CPSE Issues - September 15, 2022 (PDF)
- November 2022 - Updates of Reported CPSE Issues - November 15, 2022 (PDF)
2021
- January 2021 - Updates of Reported CPSE Issues - 1-15-21 (PDF)
- March 2021 - Updates of Reported CPSE Issues - 3-15-21 (PDF)
- May 2021 - Updates of Reported CPSE Issues - 5-15-21 (PDF)
- July 2021 - Updates of Reported CPSE Issues - July 15 2021 (PDF)
- September 2021 - Updates of Reported CPSE Issues - September 15, 2021 (PDF)
- November 2021 - Updates of Reported CPSE Issues - November 23, 2021 (PDF)
2020
- January 2020 - Updates of Reported CPSE Issues, 01.15.2020 (PDF)
- February 2020 - Updates of Reported CPSE Issues, 02.15.2020 (PDF)
- March 2020 - Updates of Reported CPSE Issues, 03.15.2020 (PDF)
- April 2020 - Updates of Reported CPSE Issues, 04.15.2020 (PDF)
- May 2020 - Updates of Reported CPSE Issues, 05.15.2020 (PDF)
- June 2020 - Updates of Reported CPSE Issues, 06.15.2020 (PDF)
- July 2020 - Updates of Reported CPSE Issues, 07.15.2020 (PDF)
- August 2020 - Updates of Reported CPSE Issues, 08.15.2020 (PDF)
- September 2020 - Updates of Reported CPSE Issues, 09.15.20 (PDF)
- October 2020 - Updates of Reported CPSE Issues,10.15.20 (PDF)
- November 2020 - Updates of Reported CPSE Issues, 11-15-20(PDF)
- December 2020 - Updates of Reported CPSE Issues, 12-15-20 (PDF)
2019
- July 2019 - Updates of Reported CPSE Issues, 07.15.2019 (PDF)
- August 2019 - Updates of Reported CPSE Issues, 08.15.2019 (PDF)
- September 2019 - Updates of Reported CPSE Issues, 09.15.2019 (PDF)
- October 2019 - Updates of Reported CPSE Issues, 10.15.2019 (PDF)
- November 2019 - Updates of Reported CPSE Issues, 11.15.2019 (PDF)
- December 2019 - Updates of Reported CPSE Issues, 12.15.2019 (PDF)
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)
Ohio Managed Care Plans
Consolidated Medicaid Plan Resource Guide (PDF)
Ambetter Manuals & Forms
For Ambetter information, please visit our Ambetter website.