Manuals, Forms and Resources

• Provider Manual 
• Medicare Advantage Provider Manual (2017)
• Allwell - Medicare Advantage Provider Manual (2018)
• Buckeye Health Plan Payment Policy Manuals

New Provider Enrollment Forms

• New Provider Enrollment Form
• Ohio Department of Insurance - New Facility Provider Request

Medicaid/General Forms

• 30-Day Readmission Payment Policy
• 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 04/2011 (PDF)*
• Federal HHS687 Consent to Sterilization Form (PDF)***
• Federal HHS687.1 Consent to Sterilization Form SPANISH (PDF)***
• Home Health Nurse & Aide Service Rate Change
• Immunization Coding & Billing Guidelines (PDF)
• Location Update Request Form (PDF)
• Medicaid Inpatient Prior Authorization Form
• Medicaid Outpatient Prior Authorization Form
• OAHP PA Home Health Form (PDF)
• OAHP PA Nursing Facility Form (PDF)
• OAHP PA Standardized Form–Medicaid (PDF)
• Pain Management Referral Form (PDF)
• Pregnancy Event Form (PDF)
• Pregnancy Notification Form (PDF)
• Pregnancy Notification Reimbursement Letter
• Provider Adjustment Request Form (PDF)
• Request to Change PCP Form (PDF)
• Waiver Services Prior Authorization Request

Medicare Forms

• Medicare Appeal Waiver of Liability Form (PDF)
• Medicare IV Home Request Process Form (PDF)
• Medicare Coverage-Determination Request Form
• Medicare and MyCare Inpatient Authorization Form
• Medicare Outpatient Authorization Form

MyCare Forms

• Medicare and MyCare Inpatient Authorization Form
• MyCare Outpatient Authorization Form
• MyCare Coverage-Determination Request Form

*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.

• Pregnancy Event Form (PDF)
• Pregnancy Notification Form (PDF)
• Pregnancy Notification Reimbursement Letter

• Member Rights & Responsibilities (PDF)
• Medicare Provider Toolkit
• Quick Reference Guide – Medicare (PDF)
• Quick Reference Guide – Medicaid (PDF)
• Quick Reference Guide – MyCare (PDF)
• HEDIS Quick Reference Guide
• Healthchek Provider Reference Manual
• MMP Key Contact List

• Home Health Agency and Home Care Providers
• Prior Authorizations, Home Health
• Nursing Facility Provider Training
• MyCare Program Overview
• Buckeye Web Portal Create an Authorization (non-waiver)
• Buckeye Web Portal Quick Billing Guide
• Buckeye Web Portal Multiple Claims Submission Wizard
• Home Modification and Vehicle Modification

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:

• ADHD Fact Sheet (PDF)
• ADHD Fact Sheet Citations (PDF)
• ADHD Brochure (PDF)

Depression:

• Depression Fact Sheet (PDF)
• Depression Fact Sheet Citations (PDF)
• What is Depression Brochure (PDF)
• Anti-Depressant Medications Brochure (PDF)

InterQual criteria are available for your review upon request.

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

• ODJFS Level of Care Rule Changes Presentation (PDF)
• OAC Level of Care Rules (PDF)
• Long Term Care & Level of Care Quick Reference Sheet (PDF)

• Appropriate Use and Safety Edits
• Biopharmaceutical Program
• Acaria Health-Supplied Biopharmaceutical Program
• Maintenance Drug List
• Preferred Drug List
• Preferred Drug List Quick Reference Guide
• Buckeye Over-the-Counter Pharmacy Program
• ADHD Quick Reference Drug List
• Alzheimer Quick Reference Guide
• Antidepressants Quick Reference Guide
• Antipsychotics Quick Reference Guide
• Hyperlipidemia Quick Reference Guide
• Diabetes Quick Reference Guide
• Proton Pump Inhibitors Quick Reference Guide