Manuals, Forms and Reference Tools

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

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

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

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

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

Telehealth

We are pleased to announce that we recently added a new form on our website to allow providers to indicate on their profile that they offer Telehealth services. If you haven't added that to your profile, please complete the form on our Demographics section of the website.

Medicaid Offers These Tips for Announcing Availability of Telehealth:

Promoting telehealth helps build awareness about how patients can easily access the care and services you provide. It's also an opportunity to remind patients not to put off routine and preventative care appointments.

Once you’re ready to let your patients know that you offer telehealth, you’ll want to communicate this in multiple ways. Think about participating in a variety of events and connecting to patients from different backgrounds. Promoting telehealth helps increase visibility of your services and educates patients about their options for accessing care.

You may consider:

• Updating your websit
• Sending an email to patients
• Mailing a letter or postcard
• Sharing information via social media such as live video streaming
• Announcing services in local newspapers and radio
• Placing brochures or handouts in multiple languages in your waiting room
• Publicizing to local community groups and religious organizations
• Attending community events such as health fairs, school, or public library events

Manuals

• Medicaid Provider Manual 2024 as of 6-11-24 (PDF)
• Medicaid Provider Manual 2023 Final v2 10-24 (PDF)
• Medicaid Provider Manual 2022-23 (PDF)
• Medicaid Provider Manual 2021 (PDF)
• Wellcare by Allwell - 2022 Medicare Advantage Provider Manual (PDF)
• Wellcare By Allwell - 2023 Medicare Advantage Provider Manual v2 10-25(PDF)
• Wellcare by Allwell - 2024 WBA Provider Manual - Final - 508C-kr (PDF)

Forms

Electronic Deposit Forms

• W9 Form (PDF)
• ACH Form (PDF)

Add New Practitioners or Facilities to Existing Contracts

• New Practitioner Enrollment Form (PDF)
• New Provider Location Form (PDF)
• Ohio Department of Insurance - New Facility Provider Request (PDF) (Medical Services Only)
• Behavioral Health Facility Application (PDF) (Behavioral Health only or facilities that provide both Behavioral Health and Medical)
• Standard Direct Practitioner Roster (Excel) (Direct Groups or facilities to use for submitting multiple practitioners)

Enrollments Must be Submitted with the Form Below:

Non-Contracted Providers

If you are not contracted with Buckeye Health Plan or the group/facility you are with does not hold a contract with us, please go to the Join Our Network page.

Provider Update and Change Forms

• Address Change
• Demographic Change
• Update Member Assignment
• Term Practitioner
• Change NPI or IRS Information

Facility Agency Update and Change Forms

Patient Liability Discrepancies

Medicaid/General Forms

• 30-Day Readmission Payment Policy (PDF)
• Abortion Certification Form (PDF)
• Advance Directives Form (PDF)
• Care Management Referral Form- Southwest Region (PDF)
• Care Management Referral Form- Northwest Region (PDF)
• Care Management Referral Form- Northeast Region (PDF)
• Care Management Referral Form- East Central Region (PDF)
• COB Dispute & Adjustment Request Form (PDF)
• Connections Referral Form (PDF)
• Acknowledgement of Hysterectomy Form rev 06-2021 (PDF)
• Consent to Sterilization - English - 2025 (PDF)
• Consent to Sterilization - Spanish - 2025 (PDF)
• Home Health Nurse & Aide Service Rate Change (PDF)
• Immunization Coding & Billing Guidelines (PDF)
• Medicaid Inpatient Prior Authorization Form (PDF)
• Medicaid Biopharmacy Outpatient Prior Authorization Form (PDF)
• Medicaid Outpatient Prior Authorization Form (PDF)
• OAHP PA Home Health Form (PDF)
• OAHP PA Nursing Facility Form (PDF)
• OAHP PA Standardized Form–Medicaid (PDF)
• Pain Management Referral Form (PDF)
• See Post Service Provider Appeals page
• Provider Claim Dispute Portal Instructions
• Request to Change PCP Form (PDF)
• Substance Use Disorder (SUD) Review Template (PDF)
• Waiver Services Prior Authorization Request (PDF)

Medicare Forms

• Medicare Inpatient Authorization Form (PDF)
• Medicare Outpatient Authorization Form (PDF)

MyCare Forms

• MyCare Inpatient Authorization Form (PDF)
• MyCare Outpatient Authorization Form (PDF)
• MyCare Coverage-Determination Request Form (PDF)

Behavioral Health Forms

• Ohio Uniform Prior Authorization Form - Community Behavioral Health Services (PDF)
• Applied Behavioral Analysis (ABA) for Autism - Authorization Form (PDF)
  
• Electroconvulsive Therapy (ECT) Form - Medicaid (PDF)
• Electroconvulsive Therapy (ECT) Form - Medicare (PDF)
• Outpatient Treatment Request Form - Medicare (PDF)
• Applied Behavior Analysis Covered Services (PDF)
• Substance Use Disorder Treatment Planning Guide (PDF)
• Medicaid Substance Use Disorder Prior Authorization Form (PDF)
• Medicaid Substance Use Disorder Residential Treatment Notification Form (PDF)

*JFS 03199 rev 04/2011 Must be used as of July 1, 2012

***Both versions 2010 and 2012 can be used as content remains unchanged.

ADHD/Depression Toolkits

Below are documents you will find helpful when working with on ADHD and depression issues with patients.

• ADHD and Depression Toolkit Introduction Letter (PDF)
• Behavioral Health & Wellness Brochure (PDF)
• Talking to Friends & Family Brochure (PDF)
• Suicide Prevention Brochure (PDF)

ADHD

• ADHD Fact Sheet (PDF)
• ADHD Fact Sheet Citations (PDF)
• ADHD Brochure (PDF)

Depression

• Depression Fact Sheet (PDF)
• Depression Fact Sheet Citations (PDF)
• What is Depression Brochure (PDF)
• Anti-Depressant Medications Brochure (PDF)

Interqual

InterQual criteria are available for your review upon request.

Prior Authorization For ASAM W/M Level of Care (Formerly known as Detox)

As a new requirement to ensure clinical consistency and coverage of Medicaid services across the full American Society of Addiction Medicine (ASAM) continuum, Buckeye must use The ASAM Criteria® in determining coverage for inpatient hospital services when the hospital provides the clinical documentation to support the review using ASAM Criteria®. Buckeye will continue to use Interqual clinical guidelines for determining inpatient hospital level of care that take into consideration all symptoms and clinical issues (SUD, psychiatric, and other medical conditions); however, for individuals with SUD conditions, Buckeye will also consider ASAM Criteria® prior to denying inpatient hospital services. When a hospital does not provide documentation to support the review using the ASAM Criteria® and the individual does not meet inpatient level of care using Interqual clinical guidelines, Buckeye will request additional documentation ASAM Criteria® for further consideration. Inpatient hospital services must be authorized if either of the following apply:

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

OAC Level of Care Rules

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

• ODJFS Level of Care Rule Changes Presentation (PDF)
• OAC Level of Care Rules (PDF)
• Long Term Care & Level of Care Quick Reference Sheet (PDF)