Updates

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.

FAQ (PDF)

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 Health offers a secure portal to submit records safely and efficiently. You will begin seeing record request correspondence from 6 Degrees Heath and we will provide additional information regarding the transition closer to the go-live date.

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:

Apple

Android  

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

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:

Hip

• 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)

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)

Shoulder

• 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

• 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

• 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)

KEY PROVISIONS:

• 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.

Questions?

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

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.

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.

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 IHD@medicaid.ohio.gov. 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 IHD@medicaid.ohio.gov. 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.