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Manuals, Forms and Reference Tools

New Provider Enrollment Forms

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.

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.

Ohio Managed Care Plans

Consolidated Medicaid Plan Resource Guide (PDF)

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.