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.

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:

Manuals

Forms

Electronic Deposit Forms

Add New Practitioners or Facilities to Existing Contracts

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

Facility Agency Update and Change Forms

Patient Liability Discrepancies

Medicaid/General Forms

Medicare Forms

MyCare Forms

Behavioral Health Forms

*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

Depression

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.