Medicaid Quick Reference Guide

PRIOR AUTHORIZATION REQUIREMENTS • MEDICAID

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Abortions, Sterilizations and Hysterectomies<br>Sterilizations do not require prior authorization.<br>Prior authorization is required for abortions and hysterectomies.<br><br>ODJFS mandated consents/attestations for all of the procedures above must be submitted with the claim.<br><br>Failure to submit a valid, signed consents/attestations will result in denial of claim payment.<br><br>Behavioral Health Services<br>• Inpatient Psychiatric Admissions<br>• SUD Partial Hospitalization/Residential<br>• Psychological Testing<br>• Electroconvulsive Therapy (ECT)<br>• ACT/IHBT Services<br><br>Cardiac Imaging<br>• Nuclear Cardiology/MPI, Stress Echocardiography, Echocardiography<br>• Visit www.RadMD.com.<br><br>Cardiac Procedures visit www.myturningpoint-healthcare.com<br><br>Diagnostic Test<br>• NIA via www.RadMD.com.<br>• 3D Mammography, CT, MRA, MRI, PET scans<br><br>DME, Orthotics and Prosthetics<br>Durable medical equipment (rental or purchase)<br>• Prosthetics and orthotics<br>• Please check the Pre-Auth code checker on the provider website to determine if Pre-Auth is required.<br><br>Experimental or Investigative Services<br>Any experimental or investigative procedure, service or drug protocol<br><br>Genetic Testing<br><br>Home Health Care Services<br>Some Home Health Care services require PA. See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/pre-auth-check/medicaid-pre-auth.html<br><br>Hospice in Any Setting<br>All services provided in the home require PA<br><br>Implantable devices – See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html<br><br>Inpatient Facility Admissions<br>• Facility to Facility Transfers including all post-acute admissions<br>• Elective or scheduled, prior to admission<br>• Urgent/Emergent admissions require notification and clinical information within 48 hours of admission<br><br>Non Participating Providers<br>Prior authorization is required for services provided by any non-participating provider	Oncology Medications<br>• New Century Health via www.my.newcenturyhealth.com<br>• Provider Phone: 1-888-999-7713, Option 1. Monday-Friday (8am-8pm)<br><br>Outpatient Services / Cardiac Rehabilitation<br>PARTICIPATING PROVIDERS ONLY – no prior authorization is required if provided in an outpatient setting (location 22 only).<br><br>Physical, Occupational, and Speech Therapy<br>PT/OT/ST – The first 30 visits for each discipline will not require prior authorization for participating providers only in an outpatient setting.<br>(The visit limitations are based on calendar year.)<br><br>Pharmacy<br>• Injectable medications<br>• See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html<br>• See the Preferred Drug List for complete details<br>• Buy and Bill Requests, Fax: 1-866-704-3066<br><br>Pregnancy Notification - Fax: 1-866 681-5125 Submit notification of expectant mothers within 7 days of the first prenatal visit<br><br>Psychological, Neuropsychological and Developmental Testing<br>• Up to 20 hours per patient per calendar year for the combined above testing<br>• Prior Authorization is required should additional testing be necessary in calendar year<br><br>Quantitative Drug Testing for Drugs of Abuse<br><br>Surgeries<br>• All elective surgical procedures will require prior authorization regardless of location<br>• See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html<br><br>Musculoskeletal Cases – TurningPoint<br>Visit www.myturningpoint-healthcare.com<br><br>Transplants<br>Transplant Evaluation Services<br><br>Transportation<br>• Scheduled Air ambulance – fixed wing<br>• No PA for stretcher transportation

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Abortions, Sterilizations and Hysterectomies Sterilizations do not require prior authorization. Prior authorization is required for abortions and hysterectomies. ODJFS mandated consents/attestations for all of the procedures above must be submitted with the claim. Failure to submit a valid, signed consents/attestations will result in denial of claim payment. Behavioral Health Services • Inpatient Psychiatric Admissions • SUD Partial Hospitalization/Residential • Psychological Testing • Electroconvulsive Therapy (ECT) • ACT/IHBT Services Cardiac Imaging • Nuclear Cardiology/MPI, Stress Echocardiography, Echocardiography • Visit www.RadMD.com. Cardiac Procedures visit www.myturningpoint-healthcare.com Diagnostic Test • NIA via www.RadMD.com. • 3D Mammography, CT, MRA, MRI, PET scans DME, Orthotics and Prosthetics Durable medical equipment (rental or purchase) • Prosthetics and orthotics • Please check the Pre-Auth code checker on the provider website to determine if Pre-Auth is required. Experimental or Investigative Services Any experimental or investigative procedure, service or drug protocol Genetic Testing Home Health Care Services Some Home Health Care services require PA. See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/pre-auth-check/medicaid-pre-auth.html Hospice in Any Setting All services provided in the home require PA Implantable devices – See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html Inpatient Facility Admissions • Facility to Facility Transfers including all post-acute admissions • Elective or scheduled, prior to admission • Urgent/Emergent admissions require notification and clinical information within 48 hours of admission Non Participating Providers Prior authorization is required for services provided by any non-participating provider

Oncology Medications • New Century Health via www.my.newcenturyhealth.com • Provider Phone: 1-888-999-7713, Option 1. Monday-Friday (8am-8pm) Outpatient Services / Cardiac Rehabilitation PARTICIPATING PROVIDERS ONLY – no prior authorization is required if provided in an outpatient setting (location 22 only). Physical, Occupational, and Speech Therapy PT/OT/ST – The first 30 visits for each discipline will not require prior authorization for participating providers only in an outpatient setting. (The visit limitations are based on calendar year.) Pharmacy • Injectable medications • See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html • See the Preferred Drug List for complete details • Buy and Bill Requests, Fax: 1-866-704-3066 Pregnancy Notification - Fax: 1-866 681-5125 Submit notification of expectant mothers within 7 days of the first prenatal visit Psychological, Neuropsychological and Developmental Testing • Up to 20 hours per patient per calendar year for the combined above testing • Prior Authorization is required should additional testing be necessary in calendar year Quantitative Drug Testing for Drugs of Abuse Surgeries • All elective surgical procedures will require prior authorization regardless of location • See Pre-Auth code checker at: www.buckeyehealthplan.com/providers/preauth-check/medicaid-pre-auth.html Musculoskeletal Cases – TurningPoint Visit www.myturningpoint-healthcare.com Transplants Transplant Evaluation Services Transportation • Scheduled Air ambulance – fixed wing • No PA for stretcher transportation

Important Phone Numbers/Addresses

Provider Services	Acaria (Biopharmacy)	Vision Claims Submission
Buckeye Health Plan<br>4349 Easton Way, Suite 300<br>Columbus, OH 43219<br>PH: 1.866.296.8731 Fax: 1.866.786.0482<br><br>For Peer to Peer discussions with a Buckeye physician call 866-246-4356 ext. 24084, or send a secure email to: BuckeyePeertoPeerNotification@centene.com	PH: 1.855.535.1815<br>Fax: 1.855.217.0926	Envolve Vision, Attn: Claims, PO Box 7548<br>Rocky Mount, NC 27804<br>PH: 1.866.442.6173
Member Services<br>PH: 246.2435 (Medicaid)	NIA<br>PH: 1.800.642.6551<br>www.RadMD.com	Paper Claims Submission<br>Buckeye Health Plan<br>PO Box 6200, Farmington, MO 63640
Concurrent Review<br>Fax: 1.866.786.1039<br>Fax: 1.866.709.1109<br>Fax: 1.866.535.4081<br>Fax: 1.866.535.2895<br>Fax: 1.866.535.7547	24-Hour Nurse Advice Line<br>PH: 1.866.246.4358<br>say "Nurse" when prompted	Electronic Claims Submission<br>Medicaid - Ohio Claims Medical<br>PH: 1.800.225.2573 ext: 6075525<br>or via e-mail at: EDIBA@centene.com<br>Payer ID 68069<br>Visit buckeyehealthplan.com/providers/resources/electronic-transactions.html
Care Management<br>PH: 1.866.246.4359<br>PH: 866-528-9920	TTY Line<br>1.800.750.0750	Medicaid - Ohio Claims Behavioral Health<br>PO Box 6150, Farmington, MO 63640<br>Claims PH: 1.877.730.2117<br>Care Mgmt PH: 1.800.224.1991<br>www.cenpatico.com
Pharmacy<br>Envolve Pharmacy Solutions<br>2425 W. Shaw Ave.<br>Fresno, CA 93711<br>PH: 1.800.460.8988<br><br>Prior Authorizations for all regions:<br>All PA requests call 1-866-246-4359<br>SN/Rehab/LTAC requests:<br>Fax: 1.866.529.0291<br>Fax: 1.866.535.4083<br>Fax: 1.866.529.0290<br><br>Home Health Care and Hospice requests<br>Fax: 1.855.339.5145	Envolve Dental<br>PH: 1.844.464.5634<br>Fax: 1.844.847.9807	Electronic Claims Submission<br>Payer ID 68068
	Dental Claims Submission<br>PO Box 22687, Tampa, FL 33622-2687<br>PH: 1.844.464.5634	Appeals Regarding Claim Payment<br>Buckeye Health Plan, PO Box 6200<br>Farmington, MO 63640-3800
	Envolve Vision<br>Provider PH: 1.866.442.6173<br>Customer Service PH: 1.800.840.7032	Appeals Regarding Medical Necessity<br>Buckeye Health Plan<br>Appeals/Grievance Department<br>4349 Easton Way, Suite 300<br>Columbus, OH 43219
	Musculoskeletal & Cardiac Procedures<br>Orthopedic and Spinal Surgical Procedures<br>Visit TurningPoint Healthcare Solutions<br>Web portal intake: www.myturningpoint-healthcare.com<br>Telephonic Intake: 1.844.378-3707<br>1.614.407.3447

Prior authorization requests for members under age 21 for screening, diagnostic and treatment services that go beyond the coverage and limitations are reviewed for medical necessity as defined in OAC 5160-1-01.

Please use the following lockbox address for provider payments –
The Payor lockbox address should no longer be used
Remitter Address - This is the address the customer will provide to their remitters. Address listed for US Mail ONLY. Include Company Name, Address, City, State, & Zip Code Buckeye Health Plan Inc. , 75 Remittance Drive - Suite 3237 - Chicago IL 60675-3237

If you wish to provide your remitters with the payment address for overnight deliveries via courier use the address below. Inform your remitters that use of this address will be for overnight deliveries only.
Overnight Address - All overnight mail by special couriers should be sent to the actual site address listed below and should reflect Lockbox Services and the Lockbox Number in the reference section of the air bill. Include Company Name, Street Address, City, State, & Zip Code
Lockbox Services 3227 (Input Lockbox Number)
Lockbox Community Plan Inc. - Suite 3237 - 350 N Orleans St Fl 9 - Chicago IL 60654-1529

Timeframes
• Claims Submission: 365 Days from the date of service
• Requests for appeal or adjustments: 180 Days from the date of the Explanation of Payment (EOP)

Claim Submission Tips
• Use current specific CPT-4, HCPCS and ICD-10 codes following Medicaid guidelines.
• Bill using the member’s MMIS number

buckeye health plan
Envolve Pharmacy Solutions
Pharmacy Help Desk: 1-800-681-6832
Effective Date:
Name:
DOB:
PCP Name:
RX BIN: 002545
RX Group: RXGM0H01
If you have an emergency, call 911 or go to the NEAREST emergency room (ER).
If you do not have Buckeye for an emergency, call us to let us know you got emergency services.
You can call the Pharmacy Help Desk at 1-800-681-6832.
NurseWise toll-free at 1-866-946-4646 and follow the prompt for "Nurse" or TTY at 1-800-750-0750. NurseWise is open 24 hours a day.

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