Manuals, Forms and Reference Tools
- Telehealth Provider Resource Guide (PDF)
- HEDIS Provider Reference Guide 2019 (PDF)
- Medicaid Quick Reference Guide (PDF)
- Medicare Quick Reference Guide (PDF)
- 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)
- MMP Key Contact List (PDF)
- EAPG 2017 Covered Codes (XLS)
- EAPG 2018 Covered Codes (PDF)
- Claims Denial Process (PDF)
- Home Health Agency and Home Care Providers (PDF)
- Prior Authorizations, Home Health (PDF)
- Nursing Facility Provider Training (PDF)
- MyCare Program Overview (PDF)
- Buckeye Web Portal Create an Authorization (non-waiver) (PDF)
- Buckeye Web Portal Quick Billing Guide (PDF)
- Buckeye Web Portal Multiple Claims Submission Wizard (PDF)
- Home Modification and Vehicle Modification (PDF)
New Provider Enrollment Forms
- New Practitioner Enrollment 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:
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
- 30-Day Readmission Payment Policy (PDF)
- Appeals Review Form (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 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 (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)
- Pregnancy Event Form (PDF)
- Pregnancy Notification Form (PDF)
- Pregnancy Notification Reimbursement Letter (PDF)
- Provider Adjustment Request Form (PDF)
- Request to Change PCP Form (PDF)
- Substance Use Disorder (SUD) Review Template (PDF)
- Waiver Services Prior Authorization Request (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)
- Medicare and MyCare Inpatient Authorization Form (PDF)
- MyCare Outpatient Authorization Form (PDF)
- MyCare Coverage-Determination Request 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)
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 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 firstname.lastname@example.org. 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.
- 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)
- 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)
- January 2021 - Updates of Reported CPSE Issues - 1-15-21
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. MyCareOHClaims@CENTENE.com Use Subject line: Patient Liability