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March 2024


Advancements in the science of genetics and genomics have led to remarkable new options for medical professionals to diagnose, treat, and prevent disease. As genetic testing has increasingly become the standard of care, our health plan is committed to providing the highest levels of access, quality, and value for members in this exciting and dynamic segment of health care.

To achieve these goals, our health plan is asking for your support in the next phase of its genetic testing program. The goals of this phase are twofold -- advance the reliability of laboratory quality information and reduce variability in billing.

Beginning June 1, 2024, Buckeye will expand the requirements for billing of genetic and molecular testing. In accordance with the Reimbursement Policy for Genetic/Molecular Test Coding Policy, all providers billing for genetic and molecular testing services will be required to adhere to the coding recommendation in the Concert Genetics portal. The policies will be posted on our Buckeye Health Plan website for your review by May 1, 2024

The portal can be accessed at Concert The quality and billing integrity requirements in the reimbursement policy will be facilitated by Concert Genetics--our partner and a software and managed services company that promotes health by providing the digital infrastructure for reliable and efficient management of genetic testing and precision medicine.

What does this mean for our laboratory partners?

We are asking you, our laboratory partner, to do the following:

  • Register with Concert Genetics.
  • Self-report on quality metrics in a common framework supplied by Concert.
  • Verify accuracy of test catalog and view coding recommendations and fee schedule.
  • Utilize Concert’s recommended codes when billing for genetic and molecular tests.

Thank you for your support and continued partnership on providing our members with access to high-quality health care at an affordable price.

Effective May 1, 2024, Buckeye Health Plan will be adding prior authorization requirements for the following code:

Service Code

Service/Procedure Description

Line of Business


Services of home health/hospice aide in home health or hospice settings, each 15 minutes.

Medicaid, MMP Duals (for Medicaid reimbursed services)

Please remember that Buckeye requires ordering, referring, and prescribing provider information on claims as required by the Ohio Department of Medicaid.  You may experience claim denials if you are not following the detailed ODM Requirements (PDF) 

Buckeye is not currently denying ordering and referring providers when they are not enrolled with the ODM, but we are expected to be doing so in the near future.

Dear Providers,

The Department of Health and Human Services (HHS) will hold an informational session for providers to share how it is responding to the cyberattack on Change Healthcare on Tuesday, March 19, 2024, at 4:00 pm ET. Deputy Secretary Andrea Palm, along with leadership from the Immediate Office of the Secretary and the Centers for Medicare & Medicaid Services (CMS), will lead the session. United Health Group will also attend and discuss their funding program.

You can register for the briefing using this link.

We expect that CMS will provide an overview of how to apply for Medicare advance and accelerated payments, and leaders from UnitedHealth Group will demonstrate how to apply for funding the company has made available to providers. No additional details on the agenda are currently available, but updates will be provided if new information is released.

As a reminder, our Change Healthcare Outage Overview Resource page on includes resources and support to help you navigate through this evolving situation, as well as details our approach to provider advances for those facing financial hardship. This page is updated routinely to ensure it is as current and helpful a resource as possible. 

Thank you for your continued partnership as we navigate the Change Healthcare outage. If you have any questions, please contact your Provider Engagement representative, visit Centene’s Change Healthcare website or Provider Services: Medicaid 866.296.8731, Wellcare by Allwell 855.766.1851 and Ambetter 877.687.1189.

As you may be aware, the ability to electronically submit claims through Change Healthcare is currently unavailable due to a cybersecurity incident that impacted its network and operations with no timeline for resolution. Availity, our preferred clearinghouse partner, is ready and available to help providers to enroll and begin submitting claims. They are offering several live training webinars for providers to get started with Availity Essentials. Webinar registration is easy via the Availity Essentials Provider Portal. Providers must be enrolled with Availity Essentials to access webinars. Step-by-step instructions for Availity Essentials enrollment can be found on the Availity Lifeline website.

Live Webinar: Use Availity Essentials to Submit Professional Claims

Join Availity to explore using the Claims and Encounters application on Availity Essentials. In this 75-minute webinar, providers will learn how to:

  • Get access and explore form options
  • Save entry time including shortcuts when entering provider, patient, and code details
  • Use key features that include options for submitting COB claims, corrected claims, and adding attachments
  • Take important steps to follow up after you submit claims
  • Navigate help, training and support tools
  • An expert Availity Essentials application trainer will also guide providers through key insights about the application and provide a downloadable quick-tips PDF that they can save to use later.

Upcoming webinar dates:

  • March 11th – 12:00 pm EST
  • March 13th – 11:00 am EST
  • March 14th – 10:00 am EST
  • March 15th – 10:00 am EST
  • March 19th - 10:00 am EST

Live Webinar: Getting Started with Electronic Data Interchange (EDI) on Availity Essentials

Join Availity experts to learn about Electronic Data Interchange (EDI) on Availity Essentials. This webinar will cover:

  • How to access the Availity EDI Companion Guide
  • Availity payer list
  • EDI reporting preferences
  • Manage your file transfer protocol (FTP) mailbox
  • Send and receive EDI files
  • EDI response files
  • Help and support resources

Upcoming webinar dates:

  • March 11th – 1:30 pm EST
  • March 13th – 3:30 pm EST
  • March 14th – 2:30 pm EST
  • March 15th – 2:00 pm EST

Registration: Webinar registration is easy via the Availity Essentials Provider Portal.

Thank you for your continued partnership as we navigate the Change Healthcare outage. If you have any questions, please contact your Provider Engagement representative, visit Centene’s Change Healthcare website or Provider Services: Medicaid 866.296.8731, Wellcare by Allwell 855.766.1851 and Ambetter 877.687.1189.


February 2024

Buckeye has updated our member benefits and provider resources for caring for patients with one or more chronic conditions such as asthma, diabetes, hypertension, cardiovascular disease, and sickle cell anemia.

  • Transportation Benefit. Buckeye continues to offer no-cost transportation to help members get to medical, dental and vision appointments, as well as to the pharmacy, grocery store, WIC appointments, or the social security administration office.
  • Pulmonary Rehabilitation Therapy. Pulmonary rehabilitation offers patients individualized treatment plans that include physical exercises, breathing techniques, nutrition education and counseling.
  • Smoking Cessation. Members who are current smokers, or who have been active smokers in the previous 12 months, could benefit from smoking cessation programming. Patients who are ready to quit or are interested in smoking less can contact their Buckeye Care Manager or call Member Services at 866-246-4358.
  • Continuous Glucose Monitors (CGM). Where clinically appropriate, Buckeye encourages the use of CGMs to manage diabetes. The Prior Authorization requirement has been lifted through both the Pharmacy (Gainwell) and Durable Medical Equipment benefits to reduce the administrative burden on our providers.
  • Diabetes Self-Management Education (DSME). To better support our providers, Buckeye has increased the reimbursement rate paid for the applicable DSME codes (G0108, G0109). Medicaid members who complete DSME may also be eligible for free groceries through our vendor partner Good Measures. Interested patients can be referred to Buckeye Member Services at 866-246-4358.
  • Blood Pressure Cuffs – for Home. Medicaid and MMP members with hypertension may receive a blood pressure monitor for their personal use, at no cost to the patient. Interested patients can contact their Buckeye Care Manager or call Member Services at 866-246-4358.
  • Sickle Cell Anemia. Does your patient have a sickle cell passport?  This includes all the basic information needed for treating Buckeye members diagnosed with sickle cell anemia. Members without this passport should contact their Buckeye Care Manager or call Member Services at 866-246-4358.

Remember, Buckeye provides members with incentives to get good healthcare. They can earn My Health Pays® rewards after completing healthy activities like a yearly wellness exam, annual screenings, exams for children, and vaccinations.

Per CMS Guidelines, effective April 1, 2024, Buckeye Health Plan Medicaid and MyCare plans will begin to deny previously excluded pregnancy diagnosis codes for Coordination of Benefits (COB).

A new federal law was enacted November 14, 2019, to modify Medicaid TPL/Third Party Liability rules related to this special treatment of certain types of care and payment allowing health plans to account for COB. See Federal Policy Guidance.

On February 21, Change Healthcare, a software and data analytics subsidiary of UnitedHealth Group’s Optum unit, experienced a cybersecurity incident that has impacted its network and operations. The cybersecurity incident has created a service disruption impacting our members and provider network in several ways.

As of now, Change Healthcare has not provided a timeline for resolution. To protect our members and providers, we have fully disconnected system access to and from Change Healthcare on February 21, 2024. We are working on multiple solutions to restore provider functionality and ensure continuity of care for our members. We will continue to provide updates as this situation evolves. You can find full details on our website.

Electronic Claim Submission

The ability to electronically submit claims to us through Change Healthcare is currently down. Providers can easily submit electronic claims to us via many alternative methods including other claims clearinghouses, our secure provider portal, and mail. Our preferred clearinghouse for electronic claims submission is Availity. To enroll, please visit the Availity Lifeline page and/or call Availity Client Services at 800-AVAILITY (800-282-4548). For step-by-step instructions for Availity, visit the resource page on our parent company Centene’s Change Healthcare website. Additional information on claims submission can be found in our Provider Manual located on our website.

Reimbursement via Paper Check and Virtual Credit Card (VCC)

Some paper check and virtual credit card payment processes have been disrupted due to this incident. We apologize for any inconvenience this causes. Please know we are working quickly to implement a new process to ensure payments are operational as soon as possible. An alternate way to speed up your payment process is to set up an automated clearing house (ACH) for electronic funds transfer (EFT). Our preferred ACH/EFT partner, PaySpan (now part of Zelis), has offered to help expedite the sign-up process for providers by calling 877-331-7154.

Chart Retrieval

Change Healthcare performs retrieval of medical records for several of our programs, such as HEDIS® and Risk Adjustment. You may have received a request via phone or fax from Change Healthcare where you either scheduled appointments or provided medical records. Change Healthcare is unable to honor any fulfillment requests at this time; however, we will be employing two of our existing medical record retrieval vendors, Datavant (formerly Ciox) and Datafied, to satisfy these prior commitments.

These retrievals are required to report on clinical quality measures and diagnosis data to Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). We ask that you please honor the same commitment dates for these vendors, even if you have already committed to providing medical records to Change Healthcare. If you have provided medical records from the time period of February 19, 2024, to current, you may be asked to provide these medical records again.

Thank you for your patience and partnership as we navigate this situation. We apologize for any inconvenience in this matter. If you have any questions, please contact your Provider Engagement representative, visit Centene’s Change Healthcare website or Provider Services: Medicaid - 866.296.8731, Wellcare by Allwell - 855.766.1851 and Ambetter - 877.687.1189.

January 2024

In 2023, Governor DeWine and ODM Director Maureen Corcoran introduced enhancements to reimbursement rates for providers participating in Ohio’s Medicaid programs. These enhancements were signed into law under HB 33 by both the House and Senate and approved by the Centers of Medicare & Medicaid Services (CMS) effective January 1, 2024.

These increases total approximately $579M, or 5%, across most codes. We are pleased to highlight that the Postpartum Care (CPT 59430) and Transportation Services saw significant increases. You will find the complete list of changes to the Billing Fee Schedule and Rates on the ODM website.  

In October, we notified you of changes to the Short Stay policy in response to CMS 2024 rules updates. Medicare Advantage plans are now required to adhere to the CMS 2 Midnight Rule when determining hospital inpatient admission level of care.

In response to the CMS 2024 rules updates Buckeye Health Plan has revised the Short Stay Policy with the following exclusions:

  1. It is the policy of Medicare health plans affiliated with Centene Corporation® that inpatient hospital stays (vs. observation) spanning less than two midnights are medically necessary when meeting any of the following criteria:
    • Admission is for a procedure on the current calendar year CMS Inpatient Only List (2023 addendum E2024 addendum E);
    • The admitting physician expects the patient to require hospital care that crosses two-midnights based on consideration of complex medical factors documented in the medical record. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;
    • The admitting physician does not expect the patient to require care that crosses two midnights, but determines, based on complex medical factors documented in the medical record that inpatient care is nonetheless necessary. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;1
    • Admission to an intermediate or intensive care unit level of care is considered medically necessary per a nationally-recognized clinical decision support tool;
    • Admission to acute hospital care at home;
    • Unexpected death during the admission;
    • Departure against medical advice from a medically necessary (per a nationally-recognized clinical decision support tool) inpatient stay;
    • Transferred from another facility, with a medically necessary (per a nationally-recognized clinical decision support tool) total length of stay greater than two days;
    • Election of hospice care in lieu of continued treatment in hospital.
  2. It is the policy of Medicare health plans affiliated with Centene Corporation that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally-recognized clinical decision support tools.

The final rule can be found at the American Hospital Association website.

IMPORTANT UPDATE: Terminations to resume effective January 23, 2024, for failure to complete Medicaid Agreement Revalidations in the Provider Network Management module

If you are currently due for a revalidation in the Provider Network Management (PNM) module, it is imperative that you take immediate action to complete and submit your revalidation application to renew your Ohio Medicaid Provider Agreement. Ohio Department of Medicaid (ODM) will begin terminating providers who fail to complete their revalidation prior to their specified deadline, starting January 23, 2024.

ODM resumed provider revalidation notices in June 2023 as part of the federally required unwinding process from the COVID public health emergency. ODM issues a series of notices with the first one delivered 120 days prior to your Medicaid agreement end date. Subsequent reminders are issued at 90 days, 60 days, and a final notice at 30 days. If you receive a revalidation notice, it is imperative that you take action to complete your revalidation on time. All providers are subject to either three- or five-year time-limited provider agreements.

How do you know if you are due for revalidation?

1. Check your mail and email.

Revalidation reminder notices are mailed and emailed to providers who are due for revalidation prior to the end of their Medicaid agreement. The email will be sent from to advise you of a revalidation notice in the PNM Correspondence folder. Please check your spam folder for this email.

2. View the Correspondence folder in the PNM module.

Revalidation notices are posted in the PNM module and can be accessed in the Correspondence folder. Please be sure to select the type of correspondence from the drop down (in this case <Enrollment Notices>), and search for the “Revalidation Notices.” Review the Accessing Communications within PNM Quick Reference Guide for step-by-step instructions.

NOTE: If you think you are due for revalidation but have not received notices, please login to the PNM module and verify that the primary contact information is accurate in accordance with your Ohio Medicaid Provider Agreement. All mailers and email notices are directed to the primary contact individual or address identified in the system.

If I am due for revalidation, what action do I need to take?

A “Begin Revalidation” option appears in the PNM Enrollment Action Selections 120 days prior to the Medicaid Agreement end date. This can be found under the “Manage Application”, “Enrollment Actions” option within the provider file. Review the Revalidation/Reenrollment Quick Reference Guide for step-by-step instructions.

For more information

For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option two, option two) or email Representatives are available Monday-Friday, 8:00 a.m.-4:30 p.m. Eastern time.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

December 2023

To assist Providers with the prioritization of ePRAF submissions, the Ohio Managed Care Plans (MCPs) have created sustainable interventions through the Technical Assistance Package and Quality Enhancer Incentive Program. The Quality Enhancer Incentive Program provides increased payments to eligible Providers who submit the ePRAF.

Please visit our Pregnancy and Prenatal Information page for more information on these interventions, along with the PRAF 2.0 submission and payment guidelines.

Updates to Diabetes Benefits in 2024

Buckeye and the Ohio Managed Care Organizations (MCOs) are working collaboratively to make diabetes management easier for providers and their patients. Diabetes education and support for the use of continuous glucose monitors (CGMs) have proven to be effective in diabetes care management.

To facilitate increased utilization of these enhanced tools, Buckeye and the other MCOs will pay an enhanced rate to providers rendering Diabetes Self-Management Education (DSME) and billing the appropriate codes: G0108 and G0109. In addition, PA is not required for members who receive a covered CGM device through durable medical equipment (DME) providers or through their pharmacy. Providers must use HCPCS codes A4239 and E2103 for CGMs provided through DME.

For additional information regarding these updates, including who to contact at each MCO for questions, see the quick reference guide.

We are excited to share a change for our Provider Update Newsletter for 2024. To better reflect the importance of the content delivered in our monthly communication, the title will now be: Buckeye Provider Bulletin. Buckeye Provider Bulletin Masthead


Beginning October, 2023, providers not enrolled for Medicaid and Marketplace Electronic Funds Transfer (EFT) payments started receiving payment via the Virtual Credit Card (VCC) program.

This program will begin for Medicare payments in 2024.

Going forward all payments will be issued either via electronic funds transfer (EFT) such as PaySpan or the Virtual Credit Card (VCC) program from Change Healthcare. 

Change Healthcare is a widely used payment option in healthcare that we are making available to our provider network.


VCC payments work like any other credit card payment. You will follow the same process as taking a credit card payment from a patient. Here’s how it works:

  • You receive a printed Explanation of Payment that includes a 16-digit card number.
  • You enter the number and the full amount of the payment into your credit/debit point-of-sale terminal before the expiration date.
  • You receive funds in the same timeframe as your other credit card payments.
  • There is no need to enroll to receive VCC payments as they are processed under the merchant agreement with your banking partner.
  • Note that your merchant/banking partner charges fees for the payment transaction.  These fees are in lieu of the check clearing fees you currently pay.

Providers that had not previously signed up for EFT, were automatically signed up for the VCC when using VCC for other health plans.

You may opt out of VCC at any time by calling 888-678-5862 or via the Echo Payments Simplified website.

If you prefer to enroll in EFT rather than VCC, please go to to access the enrollment form and instruction or call 877-331-7154.

We value your ongoing partnership and are excited to offer this new payment option to you.

As required by State and Federal governing entities, Buckeye Health Plan is committed to continuously evaluating and improving overall Payment Integrity solutions.  We have partnered with Optum who is supporting us in performing prepayment claim reviews. The purpose of this review is to verify the extent and nature of services rendered for the patient’s condition and claims are coded correctly for services billed. 

Optum’s edits will be implemented in phases and are not applied as a blanket “rule” for all claims.  This will be implemented for all lines of business – Medicaid, Medicare and Marketplace products.

Only a small number of claims that meet the criteria will be chosen for review.  Providers may experience a slight increase in written requests for medical record submission prior to payment.  These requests will come from Optum and will contain instructions for providing the documentation.  Should the requested documents not be returned, the claim(s) may be denied.  Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to partnering with you to provide the highest quality care for your patients/our members.

Buckeye, in support of Ohio Recovery Housing, is helping to spread the word about new state registration requirements for recovery housing. Providers that operate recovery housing should complete the form through OhioMHAS’ website. 

Recovery Housing Registry (PDF)

Notable pharmacy changes for Medicare plans coming in 2024

  • PBM will be moving from CVS to Express Scripts in 2024 for all Medicare plans. Members have been sent new ID cards with new pharmacy billing information.
  • Prior Authorizations will be required for GLP-1 agonists in 2024
  • The following table shows the most frequently prescribed drugs that will be non-formulary and their preferred alternatives in 2024:

Medicare Changes in 2024

Top Drug Removals With Alternatives
(Medicare Plans Only)



All MAPD Plans

Lantus vial; Lantus SoloStar insulin pen

Basaglar KwikPen insulin pen; Toujeo SoloStar insulin pen; Toujeo Max SoloStar insulin pen;  Tresiba vial; Tresiba FlexTouch insulin pen

Levemir vial; Levemir FlexPen insulin pen

Basaglar KwikPen insulin pen; Toujeo SoloStar insulin pen; Toujeo Max SoloStar insulin pen;  Tresiba vial; Tresiba FlexTouch insulin pen

Victoza pen injector

Bydureon Bcise auto-injector;  Mounjaro pen injector; Ozempic pen injector; Rybelsus tablet; Trulicity pen injector

Byetta pen injector

Bydureon Bcise auto-injector; Mounjaro pen injector; Ozempic pen injector; Rybelsus tablet; Trulicity pen injector

Flovent Diskus inhalation device;  Flovent HFA inhaler (Discontinued by manufacturer)

Arnuity Ellipta inhalation device; Pulmicort Flexhaler aerosol powder

Betoptic-S suspension eye drops

Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops

Kevzara pen injector;  Kevzara syringe

Enbrel injection;  Humira injection; Rinvoq tablet; Xeljanz tablet; Xeljanz XR tablet

(diagnosis dependent)

Ingrezza capsule

Austedo tablet; Tetrabenazine tablet

Mavyret tablet;  Mavyret pellets in packet

No impact for current utilizers; Epclusa tablets; Epclusa pellets in packet; Harvoni tablets; Harvoni pellets in packet

  D-SNP and MMP Only

Simbrinza suspension eye drops

Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops

Vyzulta eye drops

Alphagan P 0.1% eye drops; Brimonidine Tartrate eye drops; Combigan eye drops

November 2023

Step Therapy programs are developed by Wellcare's P&T Committee. They encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before “stepping up” to alternatives that are usually less cost-effective.

Step Therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective, and economically sound treatments.

The first-line drugs on Wellcare’s formulary have been evaluated through the use of clinical literature and are approved by Wellcare’s P&T Committee. Step therapy is failure of at least one different or less expensive drug prior to coverage of a drug on this list.

Drugs requiring step therapy effective January 01, 2024 are listed below. The prescriber, patient, or authorized representative may ask for an exception. Step therapy applies if the drug has not been used in the past 365 days.

Drug Name

  • Abatacept (Orencia®)
  • Ado-trastuzumab emtansine (Kadcyla®)
  • Aflibercept (Eylea®)
  • Atezolizumab (Tecentriq®)
  • Axicabtagene ciloleucel (Yescarta®)
  • Bevacizumab (Avastin®, Alymsys®, Mvasi®, Vegzelma™, Zirabev™)
  • Brentuximab vedotin (Adcetris®)
  • Brexucabtagene autoleucel (Tecartus™)
  • Brolucizumab-dbll (Beovu®)
  • Cemiplimab-rwlc (Libtayo®)
  • Certolizumab (Cimzia®)
  • Ciltacabtagene autoleucel (Carvykti™)
  • Corticosteroid intravitreal implants: dexamethasone (Ozurdex®), fluocinolone acetonide (Iluvien®, Retisert®, Yutiq™)
  • Corticotropin (H.P. Acthar®, Purified Cortrophin™ Gel)
  • Daratumumab (Darzalex®), daratumumab/hyaluronidase-fihj (Darzalex Faspro™)
  • Darbepoetin alfa (Aranesp®)
  • Denosumab (Xgeva®)
  • Durvalumab (Imfinzi®)
  • Eflapegrastim-xnst (Rolvedon™)
  • Elotuzumab (Empliciti®)
  • Emapalumab-lzsg (Gamifant™)
  • Epoetin alfa (Epogen®, Procrit®)
  • Faricimab-svoa (Vabysmo™)
  • Ferric carboxymaltose (Injectafer®)
  • Ferric derisomaltose (Monoferric®)
  • Ferric pyrophosphate (Triferic®, Triferic Avnu®)
  • Ferumoxytol (Feraheme®)
  • Filgrastim (Neupogen®, Zarxio®, Nivestym™, Granix®, Releuko®)
  • Golimumab (Simponi®, Simponi Aria®)
  • Hyaluronate derivatives: sodium hyaluronate (Euflexxa®, Gelsyn-3™, GenVisc®850, Hyalgan®, Supartz FX™, Synojoynt™, Triluron™, TriVisc™, VISCO-3™), hyaluronic acid (Durolane®), cross-linked hyaluronate (Gel-One®), hyaluronan (Hymovis®, Orthovisc®, Monovisc®), hylan polymers A and B (Synvisc®, Synvisc One®)
  • Idecabtagene vicleucel (Abecma™)
  • Immune globulins (Asceniv™, Bivigam®, Cutaquig®, Cuvitru™, Flebogamma® DIF, GamaSTAN®, GamaSTAN® S/D, Gammagard® liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, Xembify®)
  • IncobotulinumtoxinA (Xeomin®)
  • Lisocabtagene maraleucel (Breyanzi®)
  • Lurbinectedin (Zepzelca™)
  • Luspatercept-aamt (Reblozyl®)
  • Lutetium Lu 177 dotatate (Lutathera®)
  • Nadofaragene firadenovec-vncg (Adstiladrin®)
  • Natalizumab (Tysabri®)
  • Nivolumab (Opdivo®)
  • Pegfilgrastim (Neulasta®, Fulphila™, Fylnetra®, Nyvepria™, Stimufend®, Udenyca™, Ziextenzo™)
  • Pembrolizumab (Keytruda®)
  • Polatuzumab vedotin-piiq (Polivy™)
  • Ramucirumab (Cyramza®)
  • Ranibizumab (Lucentis®, Byooviz®, Cimerli™, Susvimo™)
  • RimabotulinumtoxinB (Myobloc®)
  • Rituximab (Rituxan®, Riabni™, Ruxience™, Truxima®), rituximab/hyaluronidase (Rituxan Hycela™)
  • Romiplostim (Nplate®)
  • Romosuzumab-aqqg (Evenity™)
  • Sargramostim (Leukine®)
  • Sipuleucel-T (Provenge®)
  • Teclistamab-cqyv (Tecvayli®)
  • Teprotumumab-trbw (Tepezza™)
  • Tisagenlecleucel (Kymriah®)
  • Tocilizumab (Actemra®)
  • Trastuzumab (Herceptin®, Ontruzant®, Herzuma®, Ogivri™, Trazimera™, Kanjinti™), trastuzumab/hyaluronidase (Herceptin Hylecta™)
  • Triamcinolone ER injection (Zilretta®)
  • Triamcinolone acetonide suprachoroidal injection (Xipere™)
  • Vedolizumab (Entyvio®)
  • Verteporfin (Visudyne®)

We are pleased to announce that, effective January 1, 2024, Express Scripts® will begin processing pharmacy claims for our plan members.

Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.

Members have been notified in advance and will receive a new ID card with updated pharmacy information, so that they are prepared to begin having their prescriptions filled at participating network pharmacies when this change occurs.

Providers can direct members to call the Member Services phone number listed on their ID card should they have questions about this change.

Please contact your Provider Engagement Administrator with any additional questions.

Thank you for the care you provide to our members.


Buckeye Health Plan is pleased to share that we will be transitioning from Optum to 6 Degrees Health for our clean claim reviews. The Go-Live launch is tentatively set for January 2, 2024.

This transition will be seamless for our provider community and reflects our ongoing efforts to make it easier to do business with Buckeye. 6 Degrees offers providers the ability to submit records via mail, fax or email.

You may begin seeing record request correspondence from 6 Degrees Heath.

ODM has asked us to remind you that Provider Network Management (PNM) is continuing our provider awareness and training efforts. Registration for the November 6-16 PNM module refresher training is now open. The training schedule is available on the PNM and Centralized Credentialing page. Below you will find how to register and a list of training topics.

New Sandata Mobile Connect (SMC) application for EVV Providers

A new Sandata Mobile Connect (SMC) application was released in application (app) stores in July 2023. This is an enhanced app with a focus on the end user experience. In addition to an updated look and feel that simplifies navigation, the update includes a simplified login process and efficient reset password process. For providers using their own devices, the old app will be available until June 30, 2024. Between now and then, no updates will be available for the old app, so be sure to download the new one.

The new SMC app can now be downloaded in either Android or Apple stores:



Information on the new SMC app is available online at Sandata on Demand. 

Reminder: Nursing Facility Claims Billing Value Code 31

For Nursing facility claims, Value code 31 should only be used to indicate a Lump Sum amount, and not the individual’s monthly patient liability amount as indicated in OAC 5160-3-39.1. Buckeye Health Plan will separately apply any amount billed under value code 31, on nursing claims as a separate Lump sum payment.  The Lump Sum amount will be applied in addition to the member’s monthly liability indicated to Buckeye by ODM.

Value code 31 should not be used to indicate the member’s monthly liability.  For additional guidance on billing the appropriate member liability codes, please see Ohio Medicaid companion Guides

October 2023

Effective January 1, 2024, Buckeye Health Plan is expanding our prior authorization program to include non-emergent MSK procedures. The expansion includes inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Buckeye Health Plan members.

We are pleased to announce a partnership with National Imaging Associates, Inc (NIA)* for utilization management services for non-emergent, Medical Specialty Solutions. In consideration of the aforementioned agreement, Buckeye Health Plan will terminate its current MSK program and utilization management efforts with TurningPoint as of December 31, 2023.

Under the terms of the agreement between Buckeye Health Plan and NIA, Buckeye Health Plan will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Buckeye Health Plan.

Planned for a January 1, 2024, implementation, this announcement serves as notice under your participating Buckeye Health Plan Provider Agreement of changes to the program.

Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.

The following outlines the specific procedures requiring prior authorization.

MSK Surgeries

Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries:


  • Revision/Conversion Hip Arthroplasty
  • Total Hip Arthroplasty/Resurfacing
  • Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
  • Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)


  • Revision Knee Arthroplasty
  • Total Knee Arthroplasty (TKA)
  • Partial-Unicompartmental Knee Arthroplasty (UKA)
  • Knee Manipulation under Anesthesia (MUA)
  • Knee Ligament Reconstruction/Repair
  • Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
  • Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)


  • Revision Shoulder Arthroplasty
  • Total/Reverse Shoulder Arthroplasty or Resurfacing
  • Partial Shoulder Arthroplasty/Hemiarthroplasty
  • Shoulder Rotator Cuff Repair
  • Shoulder Labral Repair
  • Frozen Shoulder Repair/Adhesive Capsulitis
  • Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)


  • Lumbar Microdiscectomy
  • Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
  • Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
  • Lumbar Artificial Disc Replacement
  • Sacroiliac Joint Fusion


  • Cervical Anterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression (without fusion)
  • Cervical Artificial Disc Replacement
  • Cervical Anterior Decompression (without fusion)


  • It is the responsibility of the ordering physician to obtain prior authorization for all interventional spine pain management procedures and MSK surgeries outlined above.
  • NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
  • Any Buckeye Health Plan prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery/procedure has met NIA’s medical necessity criteria.

Services other than MSK surgeries outlined above will continue to follow Buckeye Health Plan prior-authorization requirements for hospital admissions and elective surgeries.

We appreciate your support and look forward to your assistance in assuring that Buckeye Health Plan members receive MSK services delivered in a quality, clinically appropriate fashion.

We will provide additional information as we get closer to the implementation date.  Should you have questions at this time, please contact Buckeye Health Plan Provider Services Department at 1-866-246-4359.


* Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health.  Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”

New Policies for Medicare

•      MC.CP.MP.170 Peripheral Nerve Blocks

•      MC.CP.MP.22 Stereotactic Body Radiation Therapy

•      MC.CP.MP.69 Intensity-Modulated Radiotherapy

•      MC.CP.MP.246 Pediatric Kidney Transplantation

•      MC.CP.MP.57 Lung Transplantation

•      MC.CP.MP.101 Donor Lymphocyte Infusion

•      MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia

•      MC.CP.MP.182 Short Inpatient Stay

•      MC.CP.MP.106 Endometrial Ablation

•      MC.CP.MP.160 Wireless Pulmonary Artery Monitoring

•      CP.PP.206 Skilled Nursing Facility Leveling

•      V2.2023 Concert Genetics Genetic Testing Aortopathies and Connective Tissue Disorders

•      V2.2023 Concert Genetics Genetic Testing Cardiac Disorders

•      V2.2023 Concert Genetics Genetic Testing Dermatologic Conditions

•      V2.2023 Concert Genetics Genetic Testing Epilepsy, Neurodegenerative, and Neuromuscular Conditions

•      V2.2023 Concert Genetics Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders

•      V2.2023 Concert Genetics Genetic Testing Eye Disorders

•      V2.2023 Concert Genetics Genetic Testing Gastroenterologic Disorders (non-cancerous)

•      V2.2023 Concert Genetics Genetic Testing General Approach to Genetic Testing

•      V2.2023 Concert Genetics Genetic Testing Hearing Loss

•      V2.2023 Concert Genetics Genetic Testing Hematologic Condition (non-cancerous)

•      V2.2023 Concert Genetics Genetic Testing Hereditary Cancer Susceptibility

•      V2.2023 Concert Genetics Genetic Testing Immune, Autoimmune, and Rheumatoid Disorders

•      V2.2023 Concert Genetics Genetic Testing Kidney Disorders

•      V2.2023 Concert Genetics Genetic Testing Lung Disorders

•      V2.2023 Concert Genetics Genetic Testing Metabolic, Endocrine, and Mitochondrial Disorders

•      V2.2023 Concert Genetics Genetic Testing Multisystem Inherited Disorders, Intellectual Disability, and Developmental Delay

•      V2.2023 Concert Genetics Genetic Testing Non-Invasive Prenatal Screening (NIPS)

•      V2.2023 Concert Genetics Genetic Testing Pharmacogenetics

•      V2.2023 Concert Genetics Genetic Testing Preimplantation Genetic Testing

•      V2.2023 Concert Genetics Genetic Testing Prenatal and Preconception Carrier Screening

•      V2.2023 Concert Genetics Genetic Testing Prenatal Diagnosis via Amniocentesis, CVS or PUBS and Pregnancy Loss

•      V2.2023 Concert Genetics Genetic Testing Skeletal Dysplasia and Rare Bone Disorders

•      V2.2023 Concert Genetics Oncology Algorithmic Testing

•      V2.2023 Concert Genetics Oncology Cancer Screening

•      V2.2023 Concert Genetics Oncology Circulating Tumor DNA and Circulating Tumor Cells Liquid Biopsy

•      V2.2023 Concert Genetics Oncology Cytogenetic Testing

•      V2.2023 Concert Genetics Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies

Policies with updates

•      CP.CPC.05 Medical Necessity Criteria Hierarchy

•      Clinical Practice Guidelines

Policies Retired for Medicare

•      CP.MP.100 Allergy Testing and Therapy

•      CP.MP.101 Donor Lymphocyte Infusion

•      CP.MP.102 Pancreas Transplant

•      CP.MP.105 Digital EEG Analysis

•      CP.MP.106 Endometrial Ablation

•      CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines

•      CP.MP.108 Allogeneic Hematopoietic Cell Transplants For Sickle Cell Anemia and Beta-thalassemia

•      CP.MP.109 Panniculectomy

•      CP.MP.110 Bronchial Thermoplasty

•      CP.MP.113 Holter Monitors

•      CP.MP.114 Disc Decompression Procedures

•      CP.MP.115 Discography

•      CP.MP.116 Lysis of Epidural Lesions

•      CP.MP.117 Spinal Cord Stimulation

•      CP.MP.12 Vagus Nerve Stimulation

•      CP.MP.120 Pediatric Liver Transplant

•      CP.MP.121 Homocysteine Testing

•      CP.MP.123 Laser Therapy for Skin Conditions

•      CP.MP.126 Sacroiliac Joint Infusion

•      CP.MP.127 Total Artificial Heart

•      CP.MP.128 Optic Nerve Decompression Surgery

•      CP.MP.129 Fetal Surgery in Utero for Prenatally Diagnosed Malfunctions

•      CP.MP.130 Fertility Preservation

•      CP.MP.132 Heart-Lung Transplant

•      CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction

•      CP.MP.134 Evoked Potential Testing

•      CP.MP.136 Home Births

•      CP.MP.137 Fecal Incontinence Treatments

•      CP.MP.138 Pediatric Heart Transplant

•      CP.MP.139 Low-frequency Ultrasound and Noncontact Wound Therapy

•      CP.MP.14 Cochlear Implant Replacements

•      CP.MP.141 Non-myeloablative Allogeneic Stem Cell Transplants

•      CP.MP.142 Urinary Incontinence Devices and Treatments

•      CP.MP.143 Wireless Motility Capsule

•      CP.MP.144 Mechanical Stretching Devices for Joint Stiffness and Contracture

•      CP.MP.145 Electric Tumor Treating Fields (Optune)

•      CP.MP.146 Sclerotherapy for Chemical Endovenous Ablation for Varicose Veins

•      CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

•      CP.MP.148 Radial Head Implant

•      CP.MP.150 Phototherapy for Neonatal Hyperbilirubinemia

•      CP.MP.151 Transcatheter Closure of Patent Foramen Ovale

•      CP.MP.152 Measurement of Serum 1,25-dihydroxyvitamin D

•      CP.MP.153 Helicobacter Pylori (H Pylori) Serology Testing

•      CP.MP.154 Thyroid Hormones and Insulin in Pediatrics

•      CP.MP.155 EEG Headache

•      CP.MP.156 Cardiac Biomarker Testing

•      CP.MP.157 25-hydroxyvitamin D Testing in Children and Adolescents

•      CP.MP.158 Ambulatory Surgery Center Optimization

•      CP.MP.160 Implantable Wireless Pulmonary Artery Pressure Monitoring

•      CP.MP.162 Tandem Transplant

•      CP.MP.163 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition

•      CP.MP.164 Caudal or Interlaminar Epidural Steroid Injections

•      CP.MP.165 Selective Nerve Root Blocks and Transforaminal Epidural Injections

•      CP.MP.166 Sacroiliac Joint Interventions for Pain Management

•      CP.MP.167 Intradiscal Steroid Injections for Pain Management

•      CP.MP.168 Biofeedback

•      CP.MP.169 Trigger Point Injections for Pain Management

•      CP.MP.170 Nerve Blocks for Pain

•      CP.MP.171 Facet Joint Interventions

•      CP.MP.173 Implantable Intrathecal or Pain Pump

•      CP.MP.174 Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy

•      CP.MP.175 Air Ambulance

•      CP.MP.176 Outpatient Cardiac Rehabilitation

•      CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

•      CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing

•      CP.MP.182 Short Inpatient Hospital Stay

•      CP.MP.184 Home Ventilators

•      CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

•      CP.MP.186 Burn Surgery

•      CP.MP.188 Pediatric Oral Function Therapy

•      CP.MP.190 Outpatient Oxygen Use

•      CP.MP.194 Osteogenic Stimulation

•      CP.MP.202 Orthognathic Surgery

•      CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation

•      CP.MP.206 Skilled Nursing Facility Leveling

•      CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

•      CP.MP.210 Repair of Nasal Valve Compromise

•      CP.MP.22 Stereotactic Body Radiation Therapy

•      CP.MP.24 Multiple Sleep Latency Testing

•      CP.MP.242 Pulmonary Function Testing

•      CP.MP.243 Implantable Loop Recorder

•      CP.MP.244 Liposuction for Lipedema

•      CP.MP.246 Pediatric Kidney Transplant

•      CP.MP.247 Transplant Service Documentation Requirements

•      CP.MP.248 Facility Based Sleep Studies for OSA

•      CP.MP.26 Articular Cartilage Defect Repair

•      CP.MP.31 Cosmetic and Reconstructive Surgery

•      CP.MP.36 Experimental Technologies

•      CP.MP.37 Bariatric Surgery

•      CP.MP.38 Ultrasound in Pregnancy

•      CP.MP.40 Gastric Electrical Stimulation

•      CP.MP.43 Functional MRI

•      CP.MP.46 Ventricular Assist Devices

•      CP.MP.48 Neuromuscular and Peroneal Nerve Electric Stimulation

•      CP.MP.49 Physical Occupational and Speech Therapy Services

•      CP.MP.50 Drugs of Abuse Definitive Testing

•      CP.MP.51 Reduction Mammoplasty and Gynecomastia Surgery

•      CP.MP.53 Ferriscan R2-MRI

•      CP.MP.54 Hospice

•      CP.MP.55 Assisted Reproductive Technology

•      CP.MP.57 Lung Transplantation

•      CP.MP.58 Intestinal and Multivisceral Transplant

•      CP.MP.61 IV Moderate Sedation IVE Deep Sedation and General Anesthesia for Dental Procedures

•      CP.MP.62 Hyperhidrosis Treatments

•      CP.MP.69 Intensity Modulated Radiotherapy

•      CP.MP.70 Proton and Neutron Beam Therapies

•      CP.MP.71 Long Term Care Placement Criteria

•      CP.MP.81 NICU Discharge Guidelines

•      CP.MP.82 NICU Apnea Bradycardia

•      CP.MP.85 Neonatal Sepsis Management

•      CP.MP.86 Neonatal Abstinence Syndrome Guidelines

•      CP.MP.87 Therapeutic Utilization of Inhaled Nitric Oxide

•      CP.MP.91 Obstetrical Home Care Programs

•      CP.MP.92 Acupuncture

•      CP.MP.93 Bone-Anchored Hearing Aid

•      CP.MP.94 Clinical Trials

•      CP.MP.95 Gender-Affirming Procedures

•      CP.MP.98 Urodynamic Testing

•      CP.MP.99 Wheelchair Seating

•      CP.BH.100 Substance Use Disorders and Treatment Services

•      CP.BH.104 Applied Behavioral Analysis

•      CP.BH.124 ADHD

•      CP.BH.200 TMS for Treatment Resistant Major Depression

•      CP.BH.201 Deep Transcranial Magnetic Stimulation for Treatment of Obsessive-Compulsive Disorder

•      CP.BH.300 Biofeedback for BH Disorders

We are writing to address a critical issue affecting some of our accounts within the provider portal and to provide guidance on how to resolve it promptly.

Buckeye Password Policy

As part of our commitment to maintaining the highest level of security for our government partners, the provider portal enforces a 'One Year Password Policy.' This policy mandates that passwords be changed before 365 days. Failure to update passwords within the specified timeframe results in the user’s account locking. 

Buckeye is proactively working to identify ‘locked’ accounts and unlock them. If you have NOT reset your password within the designated timeframe, you may now be locked out.

Resolution and Next Steps

Step 1: Please go to the Buckeye Provider Portal and attempt to login:

  • If you are NOT locked out, you need to take immediate action to reset your password.
  • If you ARE locked out, you need to follow these steps.

Step 2: If you are NOT locked out:

To prevent any lock out, please do the following on the Portal Login page: 

  • Click on 'Trouble Logging In' on the portal login page. 
  • Follow the "Forgot Password" process to reset your password. 

Step 2: If you ARE locked out:

If your account is locked, you will see the Account Recovery screen.

In addition, you will receive an error message and an email that notifies you that your password change was NOT successful. Please take the following steps: 

  1. Reach out to the call center at 866.296.8731: The call center will raise an incident ticket which will help us unlock your account.  
  2. Reset Password: To regain access to the account, users must reset their password. Here's how to reset: 
    1. On the Portal Login page, click on 'Trouble Logging In'. 
    2. Follow the "Forgot Password" process to reset password. 
    3. Important: After resetting your password, your account will be reactivated.

If you have any problems, please contact Provider Services at: 866.296.8731.


Buckeye is in receipt of the below notice from ODM.  We understand many of you have already seen and your Clinical Engineering departments have acted on this notice, but Buckeye wants to ensure you are aware:

ODM would like to make the MCEs aware of the below critical recall from the FDA.   

The full announcement is available on the FDA's website

Hamilton Medical Inc. Recalls HAMILTON-C1, T1, MR-1 Ventilators for Capacitator Leaks and Short Circuits

Hamilton Medical, Inc. is recalling the HAMILTON-C1, T1, MR-1 ventilators because the capacitators may leak electrolyte fluid onto the ventilator’s control board. If the control board contacts the electrolyte fluid, the control board or installed spare parts could short circuit. As a result of the short circuit, the ventilator may switch to “Ambient State.”

The FDA has identified this as a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death.


If you have questions about this recall, contact Hamilton Medical Inc. at 1-800-426-6331 or email

When providers follow appointment access standards, emergency room visits decrease, health outcomes improve and patient trust in their primary care provider (PCP) increases. 

  • What are appointment access standards?
    These standards ensure members have timely access to care, so they get the right care, at the right time, in the right location.

  • Why do appointment access standards matter?
    Providers are required to follow the guidelines that are outlined by government agencies and in their participating provider agreement. This helps to reduce unnecessary emergency room visits and increases patient engagement with their PCP.
  • How can Health Plans help providers meet the appointment access standards?
    Health Plan staff should have a full understanding of the standards and encourage providers to follow these access standards. Providers should adhere to these required timeframes when they schedule appointments.

Refer to your Provider Manual for additional information pertaining to appointment access standards.

Sarah London Image

Centene CEO Sarah London was selected for Fortune's 2023 "Most Powerful Women," coming in at No. 40 on the list.

Sarah joins 100 women leaders, including 67 women CEOs, from organizations such as CVS, General Motors and UPS. The ranking includes the following criteria — the size and importance of the leader's business in the global economy, the health and direction of the business, the arc of the woman's career, her social and cultural influence, and how she shapes her company and the world.

Since becoming Centene's CEO in 2022, Sarah has been instrumental in guiding the organization to realize its vision to transform the health of the communities we serve. She has focused the organization on its three core lines of business and invested in programs and technology that support our ability to improve health and access to high-quality care for the members and communities we serve. 

This year, Sarah was also named one of Modern Healthcare's Top Women Leaders in Healthcare 2023. The program honors female executives who are leading change, developing policy and guiding healthcare delivery improvement. The distinction recognizes leaders from all sectors of the industry for their professional accomplishments and contributions to their organizations.

The youngest female CEO on the Fortune 500, Sarah also took part in a Fortune interview and videos where she discussed leadership, teamwork and culture.

The Comprehensive Maternal Care (CMC) re-attest links in PNM are currently not working correctly

ODM's vendor for the Provider Network Management (PNM) module is already working on this known issue. This system bug is impacting the Medicaid provider file for those that are currently participating in CMC for the 2023 program year. If a participating Medicaid ID received an invitation for next year, we recommend ensuring that users have the proper access needed and are able to see the CMC re-attest link, but to refrain from clicking on the link until the system has been fixed. 

At this time, we do not have an ETA for resolution. Additional communication will be sent once more information is known.

This is not impacting any Medicaid ID that would be enrolling in CMC for the first time. Those enrollment actions are available and working as expected. We highly recommend completing those enrollments while awaiting the system fix for continuing practices.

Login to PNM Here

Ohio Department of Medicaid (ODM) is aware trading partners are submitting Electronic Data Interchange (EDI) transactions with more than 5,000 CLM segments. Submissions of over 5,000 CLM segments are causing downstream issues and affecting the delivery of corresponding 277CAs back to trading partners.

Trading partners should remember to limit their transaction size to less than 5,000 CLM segments as required by ODM Companion Guides. This best practice is outlined in the Technical Reports Type 3 (TR3) which recommends “that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5,000 CLM segments.” This limitation also applies to the submission of batch 270 eligibility inquiries and 276 claim status inquiries.

Trading partners who have submitted more than 5,000 CLM segments in an EDI file and have not received a rejection via 999 or 824 AND have not received a corresponding 277CA and 835, should resubmit those claims.

September 2023

Effective October 20, Next Generation Medicaid managed care organizations (MCO), the OhioRISE plan, and MyCare Ohio plans must use provider data from Ohio Medicaid’s Provider Network Management (PNM) module as it is the official system of record. To ensure the provider data sent from the PNM to the managed care entities (MCE) is accurate, it is imperative that your records are updated within the PNM module. If your data in the PNM module does not match your data on the submitted claim, your claims will be denied for payment. 

Actions needed by you as a provider or a trading partner

  1. Check that all data submitted on a claim and within the PNM module (e.g., addresses, affiliations, specialties, locations) is accurate and up to date.  
  2. Access Provider Education & Training Resources within the PNM ‘Learning’ tab for step-by-step instructions. 
  3. Continue to update data as changes occur. MCEs will use this information as the system of record moving forward.

The MCEs download a complete extract of the Provider Master File (PMF) that includes all provider data daily.

For more information  

For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2, option 2) or email Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website

This year, Ohio Department of Medicaid (ODM) will be hosting a virtual CPC Fall Learning Collaborative in place of the Annual Summer Learning Session. 

Will be held on Friday, October 20, from 9:30 a.m.-12:30 p.m. via GoToWebinar. If you are interested in attending, register here for webinar.

Some of the topics to be covered include:

  • Risk stratification
  • Quality and efficiency metrics
  • CPC and managed care organization (MCO) collaboration
  • IPRO activity monitoring reviews

There will also be break out group discussions on CPC operationalization with your peers, from similar facility sizes and types.

ODJFS Rolls Out E-Signature Feature for Ohio Benefits Recipients

The Ohio Department of Job and Family Services (ODJFS) Director Matt Damschroder announced on September 13, 2023, a new electronic signature process that will save Ohioans time when applying for certain benefits by phone. 

“Beginning today, residents in all 88 counties will be able to apply, renew, or recertify for Medicaid, SNAP, cash assistance, and publicly funded childcare right from their smart phone,” said Damschroder. “The e-signature program is not mandatory, but it will be a time-saver for those who participate.”

The new e-signature process allows customers to receive a link on their smart phone, review their Rights and Responsibilities and sign in real time, which is instantly transferred to Ohio Benefits, the system used to manage food, cash, medical, and childcare assistance. It is an alternative to the existing telephonic signature process and could save up to 20 minutes for the applicant on the phone.

Summit, Ross, Vinton, and Hocking counties have been piloting e-signatures since early July. Cuyahoga and Franklin counties started in early August and Columbiana, Coshocton, Fairfield, Guernsey, Licking, Monroe, Muskingum, Noble, Perry, and Wayne counties rolled out the program August 31st.

“We’ve had a great deal of positive feedback from both counties and customers during the pilot period,” said Damschroder. “We are pleased to make this available as part of our ongoing efforts to improve the customer service for those Ohioans we serve.”

Customers can still mail, drop off, or fax applications to their county office to apply, renew, or recertify their benefits, or they can complete the same applications through the online Self-Service Portal (SSP).

Modifier SA is used when the Nurse Practitioner (NP) is assisting with any other procedure that does not include surgery in accordance with MTL No. 3336-18-01. This is currently a requirement for Medical claims, and in order to better align OH Medical with Behavioral health services, Buckeye will now require the SA modifier for non-84/95 provider types on the Behavioral health services beginning 11/01/2023.  Provider claims where the Nurse Practitioner is assisting with any other procedure that does not include surgery that are not billed with the SA modifier will be denied beginning 11/01/2023.

All Ohio Department of Medicaid (ODM) providers are required to revalidate or renew your ODM provider agreement every three years or five years. Credentialed provider types are subject to three-year provider agreements and are both revalidated and recredentialed at that interval. All other providers are subject to five-year provider agreements and must revalidate before the end date of that agreement to continue participation in Ohio Medicaid as an active enrolled provider.   

ODM mails and emails a reminder notice to the contact listed on the Primary Contact page in the Provider Network Management (PNM) module 120 days before the Ohio Medicaid provider agreement expires. To ensure you receive these notices, you must maintain a current mailing and email address.

Review the “2023 Upcoming Revalidations” file 

To provide additional support and information about provider revalidation schedules, ODM has published a 2023 Upcoming Revalidations file on the Ohio Medicaid website and can be found here. This report provides a complete list of all revalidations due in 2023. The revalidation list contains the provider’s name and National Provider Number (NPI) or Medicaid ID.

Once the revalidation workflow in PNM is initiated within the 120-day provider agreement revalidation timeframe, providers cannot initiate any other workflows to perform PNM updates (i.e., affiliations, demographic updates, requesting a new specialty, etc.) until the revalidation is complete and approved. However, updates or changes may still be made within the revalidation workflow as part of the revalidation verification process.

Note: ODM will publish a revalidation list for 2024 in early October 2023.

For More Information

For technical support or assistance, contact ODM’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2, option 2) or email Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

August 2023

Buckeye Grievances & Appeals is looking to continue the trend of making Buckeye easier to do business with. Following Prior Authorization policies will minimize the chances of needing an Appeal. Please review the key steps on our Prior Authorization website page.

Help Your Medicaid/MyCare Patients get their Incontinence Supplies Faster

When ordering incontinence supplies, remember to indicate both a primary diagnosis and the type of incontinence on the prescription. This is an ODM requirement. Without both items, the order cannot be completed and your patients will not receive their supplies.


Effective October 1st, 2023, there are changes to prior authorization requirements. Please see the PDF document below. 

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.  

CNC Medicare PA List Changes 10.01.23

Babylon Health’s telehealth services are no longer available as of August 7, 2023. Due to this change, you may receive new requests for both virtual and in-person services from Ambetter Virtual Access members as you are currently in our network.

As always, please verify each member's eligibility, benefits, and referral requirements before rendering care. You can find an example of an Ambetter Virtual Access member ID card on our website. 

Please contact Provider Services at 877-687-1189 with any questions.

In an effort to eliminate administrative burden for facility-based Hospice services, Buckeye Health Plan is removing prior authorization requirements for the following service codes, effective September 30, 2023.


Prior Authorization Changes

Service Code

Service/Procedure Description

Line of Business


Hospice inpatient respite care

Medicaid, MMP Duals


Hospice general inpatient care



Hospice long term care, room and board only

Medicaid, MMP- Duals

Important information on clinical diagnostic claims

Ohio Department of Medicaid (ODM) is aware that some claims for clinical diagnostic laboratory services are currently not being paid because system edit 103 has determined that the procedure reported on a detail line is "not an approved service for provider". 

This problem is occurring because the Fiscal Intermediary (FI) is attempting to verify the Clinical Laboratory Improvement Amendments (CLIA) certification only of the rendering provider (e.g., individual practitioner) and not of the billing provider (e.g., professional medical group).

Claims with detail lines for clinical diagnostic laboratory services that are affected by edit 103 were in 'pending' status but have been released for processing, at which point payment for the pended details will be paid or denied.

ODM is working with our vendor on a solution to this issue. We will provide updates as they become available.

Please direct any questions about this matter to

Assertive Community Treatment (ACT) is an evidence-based model of delivering comprehensive community based behavioral health services to adults with certain serious and persistent mental illnesses who have not benefited from traditional outpatient treatment. ACT is a benefit available to Medicaid and MyCare Buckeye members who meet the criteria outlined in this revised clinical policy. The first 12 months of ACT services do not require prior authorization. This policy will be available on our Policy website page on September 24, 2023.

July 2023

For claims received on or after September 1, 2023, providers may experience a slight increase in written requests for medical records to determine if documentation supports services billed for ER surgical services where the follow up was not performed in the ER setting, and the correct modifier (54) was not included with the claim. These requests will come from Optum and will contain instructions for providing requested documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement. Impacted lines of business are Medicare and Marketplace products. 

Thank you for partnering with us to provide quality health care to our members, your patients.

Columbus Public Health is offering recommended childhood vaccines at no cost to ensure all children have a healthy and safe school year. City of Columbus and Worthington residents under the age of 18 who receive a school-required vaccine from Columbus Public Health at a specific vax cash clinic will receive a $100 visa gift card onsite when they are vaccinated, while supplies last. Various locations. You must make an appointment in advance. 

Defects impacting delivery of 835 files

Ohio Department of Medicaid (ODM) is aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch on February 1. ODM understands the importance of timely and accurate data exchange and is committed to ensuring a smooth and reliable user experience. Over the last few months, ODM and its vendors have been identifying and correcting 835-related errors. As a result of the fixes, the majority of missing 835 details have been generated. A large batch was released on May 24, followed by a second batch released on June 26, and we expect another batch to be released today, July 7.

There is one remaining known issue that is currently being addressed. ODM has identified that this issue is primarily affecting hospitals claims. These files cannot be delivered since they failed SNIP edits at the Electronic Data Interchange (EDI). ODM vendors are working on implementing a fix in the coming 2-3 weeks.

If you have any questions or concerns about this issue, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday. We appreciate your understanding and your continued partnership.

Provider Network Management Disenrollment Quick Reference Guide is available

The Provider Network Management (PNM) Disenrollment Quick Reference Guide (QRG) offers step-by-step instructions on disenrolling a provider from Ohio Medicaid within the PNM module. These steps should only be completed if you wish to request the withdrawal of a provider’s enrollment with Ohio Medicaid. Once completed, the Medicaid ID assigned to that provider will no longer be active. The Disenrolling a Provider from Ohio Medicaid and other PNM QRGs are available on the PNM Learning tab.  

Note: Disenrolling a provider is not the action you should take to remove or manage a provider’s affiliation with an organization or group.

For additional questions or technical support, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday-Friday. 

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website

June 2023

Requests to Providers for MyCare Contact Information

As part of Buckeye Health Plan’s normal business practice, we may reach out to our providers to gather the latest contact information on our MyCare members. Coordination of care between providers is part of our provider agreement, which allows us to work collaboratively to support our members.

Using submitted claims information, we touch base with various types of service providers to obtain or verify updated phone numbers, addresses and other information for our members. As the member’s health plan, we want to assure you that responding to us with this requested information is not a HIPAA violation. If you receive a request from us, we ask that you please provide this information at your earliest convenience. Thank you for all you do for our members, your patients.

If you have questions, please contact Provider Services at: 866.296.8731.

Update to CMS’ Three-Day Rule effective August 1, 2023

Centers for Medicare & Medicaid Services’ three-day rule, also known as the 72-hour rule guidelines require that hospitals bundle the technical component of all outpatient diagnostic and non-diagnostic services with the claim for an inpatient stay when services are furnished in the 3 days preceding an inpatient admission.   

CMS requires that the 72 hours prior to an inpatient stay is bundled into the inpatient stay/claim and cannot be reimbursed separately.

  1. CMS requires that the 72 hours prior to an inpatient stay is bundled into the inpatient stay/claim and cannot be reimbursed separately
  2. Claims are matching based on provider TIN
  3. Professional claims are excluded
  4. Critical Access Hospital are excluded
  5. Any customization that was previously in place remains in place

Pilot Program Announcement

Buckeye Health is pleased to announce a pilot program in partnership with Ohio Sleep Treatment which specializes in treating Obstructive Sleep Apnea (OSA) with Oral Appliance Therapy (OAT).  Buckeye is evaluating OAT as an "in lieu of" therapy for Sleep Apnea patients. 

OAT is the main CPAP alternative and is recommended for mild and moderate OSA by the American Academy of Sleep Medicine (AASM).  Ohio Sleep Treatment has offices in Westerville, Circleville, and Lancaster.

Providers who wish to learn more about Ohio Sleep Treatment may contact Rob Kibler directly at:


Direct - (614) 316-2062 

Action required: PNM eLicense terminations

The Provider Network Management (PNM) module processed a monthly eLicense update on May 28 that matched the current license numbers entered in the PNM module as of that date. As a result, the system automatically terminated Ohio Medicaid providers with an expired license listed in the PNM module. On June 1, the PNM performed an automated script to reactivate affected providers in the system to allow time for providers to update this information before the next eLicense job.

What action do providers need to take?

Access the PNM module and confirm the license information is current before the next eLicense process runs on June 24. If the license information is not current, providers risk being terminated as an Ohio Medicaid provider. To prevent this from occurring in the future, all licensed Medicaid practitioners must keep their license date spans current in the PNM module.

For more information

For questions regarding this notice, please call the Ohio Department of Medicaid Integrated Helpdesk (IHD) at 800-686-1516 and select option 2; option 2 for provider enrollment. Representatives are available 8 a.m.-4:30 p.m. Eastern Time Monday-Friday.

Termination of Somatus Care Management Program for Patients with CKD/ESRD

Effective July 1, 2023, we will no longer partner with Somatus Inc., which provides care management services for members with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Some of your patients may be affected by this change.

Consequently, some of your patients may be enrolled in our internal care management program, the Centene CKD Center of Excellence. This program will continue supporting care management needs for members with CKD and ESRD.

If you have any questions, please do not hesitate to contact your Provider Engagement Administrator.

Reminder: Non-agency (independent) waiver services providers must complete 12-hours of continuing education annually

Federal and state regulations require all non-agency waiver services providers to complete at least 12 hours of continuing education annually on or before your Ohio Department of Medicaid (ODM) contract anniversary date. If unknown, your ODM contract anniversary date can be found on the ‘Specialties’ page in the Provider Network Management (PNM) module. Your fulfillment of this rule requirement is reviewed when you participate in structural compliance reviews conducted by ODM’s Provider Oversight Contractor, Public Consulting Group (PCG).

What actions do I need to take?

  • Complete 12 hours of continuing education each year prior to participating in the structural compliance review with PCG. PCG offers free continuing education courses on their website: PCG Training Materials. In addition, providers can take any qualified course or training that enhances the skills and competencies relevant to their job responsibilities and support person-centered service delivery.
  • PCG will send an email one month prior to your ODM contract anniversary date, requesting a structural compliance review. Please reply promptly or call to schedule the date and time for the review.

For questions regarding this notice, please contact PCG via email at or via phone at 877-908-1746.

Ohio Department of Medicaid in-person site visits to resume July 1, 2023

The public health emergency has ended, and Ohio Department of Medicaid (ODM) is resuming site visits for initial provider enrollments and revalidations effective July 1, 2023. Site visits had been paused without impacting provider enrollment status. Site visits are part of ODM’s provider enrollment screening process and are required by state and federal regulations for certain provider types.

What action do I need to take?

Public Consulting Group (PCG), will be contacting you to schedule a site visit, which may be conducted either virtually or onsite. Please be responsive to PCG when they contact you.

For more information

For questions regarding this notice, please email For more information about provider enrollment and resources check out the Provider Enrollment page on the Medicaid website.

May 2023

Announcing: Buckeye Health Plan Receives Health Equity Accreditation from the National Committee for Quality Assurance 

Buckeye Health Plan is delighted to share that we have received Health Equity Accreditation from the National Committee for Quality Assurance (NCQA). We are honored to be Ohio’s first managed care plan to receive Health Equity Accreditation from the NCQA. This accreditation recognizes Buckeye for providing culturally and linguistically sensitive services in more than 100 areas to eliminate healthcare disparities and support better health outcomes for our members. 

During the accreditation process, Buckeye met and exceeded standards in key focus areas including community and member engagement, disparity reduction, provider training on cultural competency and health equity and diversity, equity, and inclusion. The NCQA accreditation process included a rigorous evaluation by a health plan expert.

Buckeye is thinking in new ways about the many systems that influence health, from education and housing to transportation and public safety. Health equity is central to our work across all lines of business, including our processes, practices, programs, and products. This accreditation gives us a solid framework to build upon to ensure we make meaningful differences in the lives of those we are honored to serve. Buckeye delivers high-quality care and service to help everyone live their healthiest life.

As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. This is to inform you of the revision to existing Medicare and Marketplace effective 7-1-23. 

Policy Updates

Policy Number

Policy Name

Policy Description

Line of Business


Allergy Testing and Therapy

Change codes 86160, 86161 and 86162 from not payable to NOT payable only when billed with the following diagnosis codes:, B44.81, H10.01* through H10.45, J30.1 through J30.9, J30.0, J31.0, J45.2* through J45.998 , L20.84  , L20.89, L20.9, L23.0 through L23.9*, L25.1 through L25.9, L27.0 through L27.9 , L50.0, L50.1, L50.6, L50.8, L50.9, L56.1, L56.2, L56.3, R06.2, T36.0X5A through T50.995S , T63.001* - T63.94*, T78.00X* through T78.1XXS, T78.49XA through T78.49XS , T80.52XA through T80.52XS, T88.6XXA through T88.6XXS , Z88.0 through Z88.9, Z91.010 through Z91.018, Add the following diagnosis codes as payable with 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027 and 95028.

L20.0, L20.81-L20.83, L24.9, L30.2.

Add CPT 86001 as NOT payable.

Medicare & Marketplace



Testing for Select Genitourinary Conditions


Added 0330U and 0352U as not med nec for members over age 13 (new code for July '22 with no utilization/cost data).

Changed matching requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3. There will be no savings change from this edit.

Changed CPT 87481 from not medically necessary in any circumstance to not med nec when paired with the following dx codes, and only applied to members 13 years and over. Required the same dx code matching for new code 0353U (with no utilization/cost data):

B37.31, B37.32, L29.2, L29.3, N39.0,N72, N76.0, N76.1, N76.2, N76.3, N76.81, N76.89, N77.1, N89.8, N89.9, N90.89, N90.9, N91.0 –N91.5, N92.0, N93.0, N93.8, N93.9, N94.3, N94.4 – N94.6, N94.89, N94.9, O09.00-O09.03, O09.10-O09.13, O09.A0-O09.A3, O09.211-O09. 219,O09. 291-O09. 299,O09.30-O09.33,O09. 40-O09.43, O09.511-O09.519, O09.521- O09. 529, O09.611-O09.619, O09.621-O09.629, O09.70-O09.73, O09.811-O09.819,  O09.821-O09.829, O09.891-O09.899, O09.90-O09.93, O23.511– O23.93, 00.00,Z00.8,Z01.419,Z11.3,Z11.51,Z22.330,Z23,Z30.011 – Z30.019,Z30.02, Z30.09,Z30.40 – Z30.9,Z32.00, Z33.1, Z34.00 – Z34.03, Z34.80 – Z34.83, Z34.90 – Z34.93, Z36.0-Z36.5, Z36.81-Z36.9, Z38.00 – Z38.01, Z38.30 – Z38.31, Z38.61 – Z38.69, Z39.0 – Z39.2, Z3A.00 – Z3A.49, Z72.51 – Z72.53, Z86.19, Z97.5


Medicare & Marketplace


Effective July 1, 2023 Buckeye Health Plan will follow ODM guidance requiring use of the 33 modifier for the full reimbursement for filing the ePRAF.  Buckeye will no longer reimburse providers the full payment unless the provider files the claim for the ePRAF with the 33 modifier as stipulated by ODM.   Buckeye offered a grace period since ODM initially provided this guidance.  Please refer to the chart below. 

Payment for Completing the ePRAF

After completing the PRAF, submit a claim based on the guidelines below:

Reimbursement of ePRAF

Code + modifier


Fee Schedule Amount*

H1000 + 33

Electronic PRAF Submission



Paper/Faxed version


* Provider’s contracted rate will be applied to the fee schedule rate to determine final amount.   

See more information on the PRAF and proper billing on our website. 


Buckeye Health Plan's Payment Integrity department is implementing changes to the suite of unbundling edits with enhanced business rules to improve customer experience. Providers may see a reduction in unbundling edits starting in July of 2023, as Internal editing will reduce denials to only bundled modifier 59 code pair services which are clinically related. 

We want to provide you with a heads up on upcoming enhancements to the Provider Portal Landing Page and a Pop-Up Survey you may encounter on the portal toward the end of June.

One of the most propelling reasons for the changes, is to make the page more accessible for our users. The portal is now 508 Compliant to come in line with the governments directive to ensure that disabled members of the public have comparable access. By doing this, we also ensure that everyone’s experience on the site is elevated. While none of the functionality will be changing, how the users interact with the information is changing. Below is an overview of the capabilities/modules you can expect: 

  1. Notifications: Updated design to incorporate color coding, limit the characters allowed, and enabled the ability to set expiration dates.
  2. Personalized welcome with quick messages about the improved functionality.
  3. Admin Settings: Quick and easy access to core functionality of an Admin User.
  4. Quick Actions: Quick and easy access to Member Eligibility, New Claim, Recurring Claim, and Authorizations.
  5. Claims Overview: Dashboard of claims, segmented by Denied, Rejected, and Pending.
  6. Authorizations Overview: Quick access to inpatient and outpatient authorizations
  7. Useful links that are relevant to the user’s permissions and role.

In addition, you may encounter a Site Intercept Satisfaction Pop-Up Survey and/or a Feedback Tab Survey. To ensure you are experiencing the best possible use of the portal, we are placing short, automated pop-up intercepters to collect direct feedback from you about the portal experience.  

More details and a Quick Start Guide will be coming soon. 

Ohio Department of Medicaid will be hosting an opportunity to offer input and feedback on proposed updates to the CPC program administrative code rules (OAC 5160-19-01 and -02). ODM will be reviewing proposed changes, which will include updates to risk stratification, quality and efficiency metrics, and activities.

This meeting will take place on Thursday June 1, 2023 from 2:00 p.m. – 3:00 p.m. via GoToWebinar. If interested, please register here.

Medicare Member Plan Benefits Resume for Applicable COVID-19 Testing, Screening, and Treatment Services on May 12, 2023

Earlier this year, the Biden Administration announced that the federal Public Health Emergency (PHE) related to the COVID-19 pandemic will end on May 11, 2023.

During the PHE, we followed guidance from the Centers for Medicaid & Medicare Services (CMS) and instituted temporary waivers for select services. This action ensured that critical care could be quickly delivered to our members during a time of heightened need. Beginning May 12, 2023, these temporary waivers will expire, and our members’ Medicare plan benefits will be reinstated for the following services:



Member Liability

Prior Auth Needed?

COVID-19 Testing and Screening

(Administered by Provider)

Per member plan benefits


COVID-19 Vaccinations

$0 member cost-share for

vaccine administration*


COVID-19 Monoclonal Antibody Treatments

$0 member cost-share for

treatment administration*

Prior authorization only required for CPT code Q0221

*Vaccine ingredient cost is still covered directly by Medicare FFS.

Alongside these waivers, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. This increase applied to claims that included the applicable COVID-19 ICD-10-CM diagnosis code and met the date of service requirement. When the PHE ends on May 11, 2023, these add-on payments will no longer be included for discharge dates of service as of May 12, 2023 and thereafter.

Wellcare by Allwell is committed to providing a smooth transition for both our members and providers as we resume business as usual. While we will continue to communicate any updates to our business practices directly to our provider partners, we always highly recommend that providers verify member eligibility, benefits, and prior authorization requirements before rendering services.

April 2023

End Date of Public Health Emergency (PHE) and PASRR Impact

In March 2020, the Ohio Department of Medicaid (ODM) made a number of operational changes to its Medicaid program in response to the COVID-19 public health emergency (PHE). These changes included taking advantage of the flexibilities offered to states including but not limited to allowing nursing facilities to delay the completion of the Preadmission Screening and Resident Review (PASRR) for 30-days.

On February 9, 2023, the Department of Health & Human Services announced that the PHE will end on May 11, 2023. While there were various flexibilities granted, the 30-day delay of PASRR Level I screenings and Level II evaluations will terminate on May 11, 2023.

As such, the Center for Medicare and Medicaid Services expect states to resume full PASRR activities in accordance with state PASRR rules (OAC 5160-3-15, OAC 5160-3-15.1 and OAC 5160-3-15.2) as of May 12, 2023. Therefore, providers must also return to the pre-PHE timeframes for completing PASRR requirements and related level of care requests. As a reminder, level of care determinations must not precede the date the PASRR requirements were met.

For additional questions, please submit them to

See OhioRISE

Medicaid Providers Note:

We identified an issue where 835 files from Buckeye were not being received by OMES; therefore 835 files sent between February 1 to March 20, 2023, may be reprocessed which could cause duplication. Please make staff aware of this possibility to ensure the file is not posted a second time. If you have any questions, please reach out to Provider Services at 866-296-8731.

We apologize for any inconvenience this may cause and thank you in advance for your understanding.

March 2023

Claims Auditing – Custom Fitted or Custom Fabricated Prosthetics or Orthotics

On March 27, 2023, we notified our providers that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. For Phase 1, claims received on or after July 1, 2023, providers may experience a slight increase in written requests for medical record submission prior to payment for Custom Fitted or Custom Fabricated Prosthetics or Orthotics. We will be requesting medical records to verify documentation that supports high-dollar custom DME codes billed by the provider. These requests will come from Optum and will contain instructions for providing the documentation.

Notification for Buckeye Health Plan, Wellcare By Allwell and Ambetter Providers:

We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.

We utilize widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. The prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.

If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews. 

Please contact the applicable Provider Services listed on our home page or your Provider Engagement Administrator if you have any questions.

ODM Pause on Provider Agreement Revalidation/Recredentialing

The Ohio Department of Medicaid (ODM) paused provider agreement revalidations/recredentialing by pushing out all pending provider revalidation due dates in the Provider Network Management (PNM) module by 180 days. Dates were pushed out in the system during the week of February 6, 2023.  

The updated due dates applied to all providers who had not begun the revalidation process prior to the week of February 6, including those that already displayed the “Begin Revalidation” button.  This button indicated the provider had entered the 120-day period before revalidation is due.  A provider’s revalidation date is indicated by the Medicaid Agreement End Date field in PNM.   ODM issues a revalidation notice to the provider 120 days in advance of that date, including display of the “Begin Revalidation” button within their PNM account.  

As a provider, what action do I need to take?

  • If you do not see the “Begin Revalidation” button in the provider record, you do not need to do anything. The update will move the dates out another 180 days. 
  • If you do have the “Begin Revalidation” button, this means you are within the current 120-day window for revalidation.

EXCEPTION:  If you started a revalidation prior to the week of February 6, 2023, it must be completed and submitted, as this change cannot be applied to providers that were already in the revalidation process.

Providers are strongly encouraged to avoid potential enrollment delays by submitting revalidation applications early in the process.

For more information:  For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2) or email

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.  ODM will provide additional guidance but the 5/11/23 date is the likely date that PHE is lifted which sets in motion various timelines to unwind from provider flexibilities.   ODM will realign all revalidation dates accordingly and the MCE will access that information from the daily PMF. 

See Next Gen Contract Website Page

PA Changes Eff April 1, 2023

Service Code

Service/Procedure Description


A4239 (Formerly Code K0553, now retired)

Supplies, Continuous Glucose Monitoring

Allow 1 unit per month billed- PA required for over benefit limit only

E2103 (Formerly Code K0554, now retired)

Receiver/Monitor, Continuous Glucose Monitor

Allow 1 monitor every 3 years- PA required for over benefit limit only


External Transmitter

Allow up to 2 per benefit year- PA required for over benefit limit only


External Receiver/Monitor

Allow 1 per benefit year- PA required for over benefit limit only

See Next Gen Contract website page

February 2023

Effective April 1, 2023

Policy Number

Policy Name

Policy Description


Ambulatory EEG

Policy is being retired across all lines of business


Testing for Rupture of Fetal Membranes

Policy is being retired across all lines of business due to changes in standards of care.


Holter Monitors

Retiring for Medicare only as the LCDs are more lenient


Low-frequency ultrasound wound therapy

Retiring for Medicare only as the LCDs are more lenient


Measurement of Serum 1,25-dihydroxyvitamin D

Retiring for Medicare only as the LCDs are more lenient


Ultrasound in Pregnancy

Added new-for-2022 diagnosis codes as medical necessity/payable with 76811


Evoked Potential Testing

Changed configuration so the edits don't apply to outpatient surgeries by matching revenue codes

Retire for Medicare


Extended Ophthalmoscopy

Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92201/92202: , E09.37X1, E09.37X2, E09.37X3, E10.37X1, E10.37X2, E10.37X3, E11.37X1, E11.37X2, E11.37X3, H20.011, H20.012, H20.013, H20.021, H20.022, H20.023, H20.031, H20.032, H20.033, H20.041, H20.042, H20.043, H20.11, H20.12, H20.13, H20.21, H20.22, H20.23, H20.811, H20.812, H20.813, H20.01, H20.02, H20.03, H21.301, H21.302, H21.303, H21.311, H21.312, H21.313, H21.321, H21.322, H21.323, H21.341, H21.342, H21.343, H21.351, H21.352, H21.353, H21.531, H21.532, H21.533, H21.541, H21.542, H21.543, H21.551, H21.552, H21.553, H35.051, H35.052, H35.053, H35.21, H35.22, H35.23, H47.231, H47.232, H47.233, P07.01, P07.02, P07.03, P07.14, P07.15, P07.16, P07.17, P07.18, P07.21, P07.22, P07.23, P07.24, P07.25, P07.26, P07.31, P07.32, P07.33, P07.34, P07.35, P07.36, P07.37, P07.38, P07.39, Q85.01, Q85.02, Q85.03, S05.41XA, S05.41XD, S05.41XS, S05.42XA, S05.42XD, S05.42XS, T74.4XXA, T74.4XXD, T74.4XXS.  Remove the following ICD-10 codes to the list of diagnoses that are payable when billed with 92201/92202:, H31.101, H31.102, H31.103, S05.71XA, S05.71XD, S05.71XS, S05.72XA, S05.72XD, S05.72XS

Retire all edits for Medicare LOB as the LCDs are more lenient



Fluorescein Angiography

Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92235: B20, B39.5, H33.111, H33.112, H33.113, H35.21, H35.22, H35.23, H35.361, H35.362, H35.363, H43.11, H43.12, H43.13, H43.821, H43.822, H43.823, Q14.8

Retire all edits for Medicare LOB as the LCDs are more lenient.


Fundus Photography

Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92250:

Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92250: A51.43, A52.15, B25.8, G93.2, H33.121, H33.122, H33.123, Q14.8, S05.41XA, S05.41XD, S05.41XS, S05.42XA, S05.42XD, S05.42XS, S05.61XA, S05.61XD, S05.61XS, S05.62XA, S05.62XD, S05.62XS, Z85.840.  Remove the following ICD-10 codes from the list of diagnoses that are payable when billed with 92250:, C69.01, C69.02, C69.11, C69.12, C69.51, C69.52, D49.89, Q87.1

Retire all edits for Medicare LOB as the LCDs are more lenient.


External Ocular Photography

Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92285: , A18.51, A18.54, A50.31, B00.53, B30.0, B30.1, B30.2, B30.3, C44.1922, C44.1991, C44.1992, C69.51, C69.52, C69.61, C69.62, C69.81, C69.82, D09.21, D09.22, D31.51, D31.52, H00.011, H00.012, H00.014, H00.015, H00.021, H00.022, H00.024, H00.025, H00.031, H00.032, H00.034, H00.035, H00.11, H00.12, H00.14, H00.15, H02.881, H02.882, H02.884, H02.885, H02.88A, H02.88B, H04.011, H04.012, H04.013, H04.021, H04.022, H04.023, H04.031, H04.032, H04.033, H04.111, H04.112, H04.113, H04.131, H04.132, H04.133, H04.161, H04.162, H04.163, H04.311, H04.312, H04.313, H04.321, H04.322, H04.323, H04.331, H04.332, H04.333, H04.411, H04.412, H04.413, H04.421, H04.422, H04.423, H04.431, H04.432, H04.433, H04.511, H04.512, H04.513, H04.521, H04.522, H04.523, H04.531, H04.532, H04.533, H05.011, H05.012, H05.013, H05.021, H05.022, H05.023, H05.031, H05.032, H05.033, H05.041, H05.042, H05.043, H05.111, H05.112, H05.113, H05.121, H05.122, H05.123, H05.211, H05.212, H05.213, H05.221, H05.222, H05.223, H05.231, H05.232, H05.233, H05.241, H05.242, H05.243, H05.251, H05.252, H05.253, H05.261, H05.262, H05.263, H05.311, H05.312, H05.313, H05.321, H05.322, H05.323, H05.331, H05.332, H05.333, H05.341, H05.342, H05.343, H05.351, H05.352, H05.353, H05.411, H05.412, H05.413, H05.421, H05.422, H05.423, H05.51, H05.52, H05.53, H05.811, H05.812, H05.813, H05.821, H05.822, H05.823, H16.241, H16.242, H16.243, H20.11, H20.12, H20.13, H20.21, H20.22, H20.23, H20.811, H20.812, H20.813, H20.821, H20.822, H20.823, H21.331, H21.332, H21.333, H21.561, H21.562, H21.563, H21.81, H27.111, H27.112, H27.113, H27.121, H27.122, H27.123, H27.131, H27.132, H27.133, H44.011, H44.012, H44.013, H44.111, H44.112, H44.113, H44.121, H44.122, H44.123, H44.131, H44.132, H44.133, S00.211A, S00.212A, S00.221A, S00.222A, S00.241A, S00.242A, S00.251A, S00.252A, S00.261A, S00.262A, S05.01XA, S05.01XD, S05.01XS, S05.02XA, S05.02XD, S05.02XS.  Remove the following ICD-10 codes from the list of diagnoses that are payable when billed with 92285:, C44.131, H18.501, H18.502, H18.503

Retire all edits for Medicare LOB as the LCDs are more lenient.


Visual Field Testing

 Add the following ICD-10 codes to the list of diagnoses that are payable when billed with 92081-3: , B58.01, C75.3, C79.31, D35.4, D43.3, E05.20, E05.21, E05.30, E05.31, E05.40, E05.41, G45.1, G45.2, G46.0, G46.1, G46.2, H02.211, H02.212, H02.214, H02.215, H02.21A, H02.21B, H02.21C, H02.221, H02.222, H02.224, H02.225, H02.22A, H02.22B, H02.22C, H02.231, H02.232, H02.234, H02.235, H02.23A, H02.23B, H02.23C, H02.841, H02.842, H02.844, H02.845, H02.851, H02.852, H02.854, H02.855, H05.121, H05.122, H05.123, H17.01, H17.02, H17.03, H17.11, H17.12, H17.13, H17.811, H17.812, H17.813, H17.821, H17.822, H17.823, H21.331, H21.332, H21.333, H31.011, H31.012, H31.013, H31.021, H31.022, H31.023, H33.121, H33.122, H33.123, H43.01, H43.02, H43.03, H43.11, H43.12, H43.13, H43.21, H43.22, H43.23, H43.311, H43.312, H43.313, H43.821, H43.822, H43.823, H44.21, H44.22, H44.23, H44.311, H44.312, H44.313, H44.411, H44.412, H44.413, H44.421, H44.422, H44.423, H44.431, H44.432, H44.433, H44.441, H44.442, H44.443, H44.511, H44.512, H44.513, H44.521, H44.522, H44.523, H44.531, H44.532, H44.533, H44.611, H44.612, H44.613, H44.621, H44.622, H44.623, H44.631, H44.632, H44.633, H44.641, H44.642, H44.643, H44.651, H44.652, H44.653, H44.691, H44.692, H44.693, H44.711, H44.712, H44.713, H44.721, H44.722, H44.723, H44.731, H44.732, H44.733, H44.741, H44.742, H44.743, H44.751, H44.752, H44.753, H44.791, H44.792, H44.793, H44.811, H44.812, H44.813, H44.821, H44.822, H44.823, H53.451, H53.452, H53.453, H57.02, H57.03, H57.04, H57.051, H57.052, H57.053, I60.2, I63.013, I63.033, I63.113, I63.133, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I67.850, M31.6, S05.11XA, S05.11XD, S05.11XS, S05.12XA, S05.12XD, S05.12XS, S06.0X0A, S06.0X0D, S06.0X0S, S06.0X1A, S06.0X1D, S06.0X1S, S06.0X9A, S06.0X9D, S06.0X9S, S06.1X0A, S06.1X1A, S06.1X2A, S06.1X3A, S06.1X4A, S06.1X5A, S06.1X6A, S06.1X9A, S06.2X0A, S06.2X1A, S06.2X2A, S06.2X3A, S06.2X4A, S06.2X5A, S06.2X6A, S06.2X9A, S06.300A, S06.301A, S06.302A, S06.303A, S06.304A, S06.305A, S06.306A, S06.309A, S06.310A, S06.311A, S06.312A, S06.313A, S06.314A, S06.315A, S06.316A, S06.319A, S06.320A, S06.321A, S06.322A, S06.323A, S06.324A, S06.325A, S06.326A, S06.329A, S06.340A, S06.341A, S06.342A, S06.343A, S06.344A, S06.345A, S06.346A, S06.349A, S06.350A, S06.351A, S06.352A, S06.353A, S06.354A, S06.355A, S06.356A, S06.359A, S06.370A, S06.371A, S06.372A, S06.373A, S06.374A, S06.375A, S06.376A, S06.379A, S06.380A, S06.381A, S06.382A, S06.383A, S06.384A, S06.385A, S06.386A, S06.389A, S06.4X0A, S06.4X1A, S06.4X2A, S06.4X3A, S06.4X4A, S06.4X5A, S06.4X6A, S06.4X9A, S06.5X0A, S06.5X1A, S06.5X2A, S06.5X3A, S06.5X4A, S06.5X5A, S06.5X6A, S06.5X9A, S06.6X0A, S06.6X1A, S06.6X2A, S06.6X3A, S06.6X4A, S06.6X5A, S06.6X6A, S06.6X9A, S06.810A, S06.811A, S06.812A, S06.813A, S06.814A, S06.815A, S06.816A, S06.819A, S06.820A, S06.821A, S06.822A, S06.823A, S06.824A, S06.825A, S06.826A, S06.829A

Retire all edits for Medicare LOB as the LCDs are more lenient.

In response to your feedback, we have removed 16 services from our prior authorization list effective April 1, 2023:

PA Removals Eff April 1, 2023

Service Code

Service/Procedure Description



Cystic Fibrosis Carrier Screen



PT Services



Fetal Chromosomal Screen



Familial dysautonomia



Injections ganglion cysts/plantar fascia



Arthrocentesis, aspiration and/or injection, intermediate joint or bursa



Antibody testing human leukocyte antigens (HLA)



Nerve Graft Required PA for Non Par only.  This will now be NO AUTH REQUIRED FOR ALL PROVIDERS



Therapeutic Activities



Fluoroscopic guidance for needle placement

No PA for All Providers


Testing (genetic) with Thyroid Biopsies



Speech Treatments



Facility charges around dental procedures done in hospital OR or Outpatient Surgery locations

No PA for All Providers


Anesthesia charges for dental procedures done in hospital surgery,  Outpatient Surgery locations




Buckeye Health Plan is aligning with Ohio Department of Medicaid PA requirements for Continuous Glucose Monitoring supplies.  PA requirements for network providers will be required if monthly/yearly amounts are more than the ODM recommended amounts below: 

PA Changes Effective April 1, 2023





Supplies, Continuous Glucose Monitoring

Allow 1 unit per month billed- PA required for over benefit limit only


External Transmitter

Allow up to 2 per benefit year- PA required for over benefit limit only

Buckeye Health Plan is adding Prior Authorization Requirements for the following code effective April 1, 2023:

PA Additions Effective April 1, 2023





Gradient Compression Stocking


January 2023 

See Next Gen Contract Website Page

See Next Gen Contract Website Page

See Next Gen Contract Website Page

August 2022

(ODM apologizes for the error found in a communication sent out earlier this month. They stated that all demographic updates, including the CPC contact information, needed to be done in the MITS system by Aug 20 or the change will have to be held until Oct 1. The correct date is Aug 31st. Please see the corrected communication below.)

CPC Enrollment for the 2023 Program Year

The enrollment period for the CPC program is again slated for October. ODM anticipates sending out invitations to those who are eligible in early September 2022. Invitations will be sent via email to the CPC contact found in the MITS Secure Provider Portal. 

Beginning Aug. 31, all provider demographic and agent maintenance update functionality will be closed for conversion of data in MITS. ENROLLED PROVIDERS SHOULD UPDATE THEIR DEMOGRAPHIC INFORMATION IN MITS BY AUGUST 31 or plan to hold updates until Oct. 1. It is therefore vital to make sure updates are completed by Aug. 31 to ensure all CPC invitations are received.

For assistance with how to update your demographic information, refer to the training video found on the ODM website. If additional assistance is needed, contact the Provider Hotline 800-686-1516

July 2022

June 2022

May 2022

April 2022