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Manuals, Forms and Resources

New Provider Enrollment Forms

Enrollments Must be Submitted with the Form Below:

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 

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.

Please complete the PRAF 2.0 via the Nurture website. This form will ensure your patient maintains insurance coverage during their pregnancy and allows providers to easily order progesterone. Please review the Web-Based Risk Assessment Form PRAF 2.0 Information link for instructions on how to access the Nurture Website. You will find a provider manual and YouTube instructional video.
 
Submission of Buckeye’s Notficiation of Pregnancy (NOP) (PDF) will allow us to review any risks or barriers your patient may have during their pregnancy. NOP's can be submitted through our Provider Portal.
 
The first NOP is reimbursed at different values depending on when it is received: 
  • First trimester- 59899 U1- $75
  • Second trimester- 59899 U2- $50
  • Third trimester- 59899 U3- $25
    • A second and third NOP can be reimbursed at $25 regardless of the trimester

Please see the Pregnancy Notification Reimbursement Letter (PDF) for more information. 

If your patient gives birth, please alert Buckeye by submitting the Pregnancy Event Form (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.

Ohio Managed Care Plans

Consolidated Medicaid Plan Resource Guide (PDF)

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.