Manuals, Forms and Resources

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

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)
• Behavioral Health CMHC_SUD Roster (Excel)
• 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 

• Facility Change Form 

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 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 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)
• Waiver Services Prior Authorization Request (PDF)

Medicare Forms

• 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

• 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.

• Notification of Pregnancy [NOP] Form (PDF)
• Pregnancy Event Form (PDF)
• Pregnancy Notification Reimbursement Letter (PDF)

For pregnant patients, Buckeye Providers may use the NOP form above, or submit the PRAF 2.0 form by following the instructions below on ODM's site:

• Web-based Pregnancy Risk Assessment Form [PRAF] 2.0 Information
• NurtureOhio Website to Submit PRAF

• Buckeye Products Overview & ID Card Reference Sheet (PDF)
• Member Rights & Responsibilities (PDF)
• Medicare Provider Toolkit (PDF)
• Qualified Medicare Beneficiaries (QBM) Billing FAQ (PDF)
• Quick Reference Guide – Medicare (PDF)
• Quick Reference Guide – Medicaid (PDF)
• Quick Reference Guide – MyCare (PDF)
• HEDIS Quick Reference Guide (PDF)
• Healthchek Provider Reference Manual (PDF)
• MMP Key Contact List (PDF)
• EAPG 2017 Covered Codes (XLS)
• EAPG 2018 Covered Codes (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)

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)

• MAC Appeals Process (PDF)
• Appropriate Use and Safety Edits (PDF)
• Acaria Health-Supplied Biopharmaceutical Program (PDF)
• Maintenance Drug List (PDF)
• Preferred Drug List (PDF)
• Preferred Drug List Quick Reference Guide (PDF)
• ADHD Quick Reference Drug List (PDF)
• Alzheimer Quick Reference Guide (PDF)
• Antidepressants Quick Reference Guide (PDF)
• Antipsychotics Quick Reference Guide (PDF)
• Hyperlipidemia Quick Reference Guide (PDF)
• Diabetes Quick Reference Guide (PDF)
• Proton Pump Inhibitors Quick Reference Guide (PDF)