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Prior Authorization

Please note, failure to obtain authorization may result in administrative claim denials. Buckeye Health Plan providers are contractually prohibited from holding any member financially liable for any service administratively denied by Buckeye Health Plan for the failure of the provider to obtain timely authorization.

Check to see if a pre-authorization is necessary by using our online tool.

Expand the links below to find out more information.

As the Medical Home, PCPs should coordinate all healthcare services for Buckeye Health Plan members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Some services require prior authorization from Buckeye Health Plan in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

Buckeye Health Plan’s Medical Management department hours of operation are 7a.m. - 7p.m. EST, Monday thru Friday (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within one (1) business day following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

Prior Authorization Updates

Providers, you can check this section of the website for any changes to the Buckeye Prior Authorization policies/processes.

Important Updates Effective January 1, 2019

On January 1, 2019, prior authorization will be required for the below J codes in all care settings including inpatient hospital and outpatient hospital or ambulatory care center:

• Fluocinolone acetonide, intravitreal implant, J7311
• Fluocinolone acetonide intravitreal implant, J7313
• Hyaluronan or derivative, gel-syn, J7328
• Tacrol Envarsus xr, J7503
• Netupitant palonosetron, J8655
• Aldesleukin, J9015
• Belinostat, J9032
• Bendeka, J9034
• Bortezomib, J9041
• Cabazitaxel, J9043
• Cyclophosphamide, J9070
• Daratumumab, J9145
• Leuprolide acetate implant, J9219
• Olaratumab, J9285
• Obinutuzumab, J9301
• Ramucirumab, J9308
• Temsirolimus, J9330
• Pegloticase, J2507

Important Updates Effective April 15, 2015

Important Updates Effective November 1, 2014:

Update Posted December 18, 2012:

We know that recently you’ve been experiencing some issues with J9035 and J9355 authorizations and we apologize for any inconveniences this may have caused. Our goal is to continue to work with you to help ensure that you are able to provide your patients the best care possible.

Effective, February 1, 2013, all participating Hematologists and Oncologists will be required to receive prior authorization before administering injectable drugs with costs over $250. If drugs are administered without authorization, the claim will be denied and the provider will not receive payment. There are some exceptions to this policy, so please call Provider Services to determine if a drug needs prior authorization.

We are reviewing denials weekly for claims that have been denied due to the new authorization requirements and will override these denials until January 31.