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Manuals, Forms and Reference Tools

Hospice Nursing Facility Room and Board (HCPC T2046)

Buckeye Health Plan requires nursing facility room and board hospice services to be billed using the HCFA (CMS-1500).  The name of the nursing facility in which the services were delivered must be placed in Box 32 and the National Provider Identifier (NPI) related to the nursing facility must be placed in 32a.

Hospice Ventilator and Ventilator Weaning (Revenue Codes 0410/419)

Billing for Hospice Vent/Vent Weaning will only be accepted on a Uniform Billing (UB) form. Claims submitted on a CMS 1500 form will be denied for incorrect billing. Nursing facility hospice (T2046) and vent/vent weaning services are not billable on the same date of service. 

The below guidance should be followed for Hospice Vent/Vent-Weaning billing. If not specifically noted below, all other fields should be billed according to the Uniform Billing Editor facility claim submission billing requirements.

  • UB-04 Box 80 – The name and NPI of the nursing facility (NF) where the hospice room and board services are being performed must be included. If the required information is left blank, the claim will be denied for incorrect billing. Buckeye Health Plan will validate the service location and if it is not a certified facility, the claim will be denied for incorrect billing.
  • Type of Bill – 81X/081X: If the claim is billed with the incorrect Type of Bill, the claim will deny as incorrect billing.
  • HCPCS Code: This field should be left blank. If information is present the claim will deny as incorrect billing. Facilities should not bill Hospice Room and Board code T2046 or any other HCPCS Code.
  • When billing for Ventilator and/or Ventilator Weaning services, the diagnosis code Z99.11 must be included.

Hospice NF RB Billing Guidance Highlights (PDF)

Electronic Deposit Forms

Add New Practitioners or Facilities to Existing Contracts

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

Behavioral Health 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.

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:

  1. The request for admission or continued stay meets inpatient level of care criteria using Interqual clinical guidelines for hospital services, or:
  2. The request for admission or continued stay meets ASAM level 4.0 or 3.7 criteria.

AS 4.0 Documentation Form (PDF)

Please click on the documents below for more information about new Medicaid Level of Care Rule Changes that became effective March 19, 2012.






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.  Use Subject line: Patient Liability

Patient-Client Liability Reconciliation Form(PDF)

Ohio Managed Care Plans

Consolidated Medicaid Plan Resource Guide (PDF)

Ambetter Manuals & Forms

For Ambetter information, please visit our Ambetter website.