Manuals, Forms and Resources
Pregnancy and Prenatal Information
Please complete the PRAF 2.0 via the ODM PRAF 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).
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:
- 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)
- 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 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.
- HEDIS Provider Reference Guide 2019 (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)
- 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)
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.
- Envolve Prior Authorization Form with Update Fax Number (PDF) - Effective June 1, 2019
- 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)
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 email@example.com. 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.