Prior Authorization Medical - Medicaid and Medicare

Please note, failure to obtain authorization may result in administrative claim denials. Buckeye Health Plan providers are contractually prohibited from holding any member financially liable for any service administratively denied by Buckeye Health Plan for the failure of the provider to obtain timely authorization.

Important Information: How Preauthorization Leads to Faster and Smoother Processing

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 below.

• Providers can use the Prior Auth Check Tool, located on the Buckeye Health Plan website.
• Failure to obtain the required prior authorization may result in a denied claim.
• Denials for not obtaining an authorization may not be eligible for a medical necessity appeal review.
• All out-of-network services require prior authorization (excluding Emergency Room and family planning).
• Buckeye recognizes that there are events or unplanned circumstances that may result in the need for a retrospective medical necessity review. To minimize administrative burden for the provider, retrospective reviews should be requested prior to submitting a claim to Buckeye.
  • A retrospective review request that includes the clinical documentation to support medical necessity for the services can be submitted via the Provider Portal or fax to 866-529-0290.
  • Retrospective member eligibility
  • Retrospective knowledge of Buckeye eligibility
  • Service/Procedure change due to unavoidable circumstances
  • Urgent service required

  Thank you for the care you provide our Buckeye members, your patients. Together, we make their outcomes and your experience even better.

  Prior Authorizations - Necessity and Submission

  Prior Authorizations are required on some services for the provider to be reimbursed.

  1. To determine if a service needs prior authorization use our Prior Authorization Prescreen Tool.
  2. If a service requires prior authorization, please note:
     a. Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.
     b. Authorization requests should be submitted via our secure web portal and should include all necessary clinical information.
     c. Urgent requests for prior authorization should be called in as soon as the need is identified at 855-766-1851.

  To submit a Prior Authorization for approval.

  1. Enter the portal at Buckeye Health Plan website.
  2. Access the member’s record.
  3. Select the New Authorization option. The Authorization screen will appear with the member’s data pre-populated.

  Complete the Authorization Form:

  1. Select the Service Type. The Requesting Provider search box appears.
  2. Enter the provider’s last name or NPI number. A list of provider names and locations appear.
  3. Choose the name of the provider at the location that matches your search.
  4. Enter the primary diagnosis code.
     - To add additional diagnosis codes, click the +sign.
  5. Enter the ICD code and click Next.
  6. Scroll down on the right panel. The second service line displays the provider and service date information.
     - To add additional services lines, click the +sign.
  7. 'Finish Up' auto populates the user’s name, phone, fax and email address.
  8. The questionnaire that displays will vary based on the service type selected. Enter n/a if additional information is not applicable.
  9. Click Submit. A success message appears. Click the X to close the window.

  Prior Authorization requests may take 24-48 hours to display on the Authorization list.

  Submitted authorizations display for 90 days.

  For more nformation, see pages 28-33 of the Provider Portal Manual located on the landing page of the provider portal.

  No Referrals Needed

  As the Medical Home, PCPs should coordinate all healthcare services for Buckeye Health Plan members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

  Emergency Room and Post Stabilization Services Never Require Prior Authorization

  Buckeye’s Medical Management department hours of operation are 8:00 to 5:00 weekdays (excluding holidays). After normal business hours, Envolve nurse line staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within two (2) business days following the admit date.

  We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 14 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.

  Medicare

  Medical Prior Authorization Information

  Medicare Prior Authorizations Changes Effective 7-1-23 (PDF)

  Medicare Appendix A Part B Drug List as of 7-1-23 (PDF)

  Medicare Prior Authorizations as of January 1, 2023 (PDF)

  MEDICARE/Wellcare By Allwell Inpatient escalations:

  For all Medicare Outpatient authorization escalations: 800-225-2573 Ext 6035986

  Medicare Part B Drug List as of January 1, 2023 (PDF)

  Medicare Prior Authorization Changes Effective 7-1-22

  Prior Authorization Updates up to May 2021

  See the PA Latest News for more recent updates.

  Ambetter from Buckeye Health Plan has Reduced Prior Authorization Requirements

  In response to your feedback, Buckeye has removed 25 services from our prior authorization list effective March 31, 2021. View the full list (PDF).
  

  Buckeye Health Plan has Reduced Prior Authorization Requirements

  In response to your feedback, we have removed 22 services from our prior authorization list effective March 31, 2021. View the full list (PDF) and review our Medicaid PA Quick Reference Guide for more information on prior authorization and important contacts.

  InterQual Connect™

  Buckeye Health Plan - Secure Provider Portal: effective April 15, 2021

  Buckeye values the relationships we have with our provider partners and works to ensure that doing business with us is easy and straightforward. A key component of meeting provider needs is our secure Provider Portal, which enables providers to conduct business with Buckeye from the convenience of their desktops seamlessly and in real time.

  We are pleased to announce effective April 15, 2021, the integration of an exciting new tool, InterQual Connect™ in our Secure Provider Portal. Adding features that will simplify the provider experience and offers several new capabilities.

  • Streamlines web authorization request
  • Provides easy access to InterQual Connect to complete medical review
    • Completed InterQual medical review will automatically be included with your web authorization submission
    • Possible same-day approval based on outcome of a completed InterQual medical necessity review

    We believe the enhancements to our Provider Portal will create a more user-friendly experience and enhance your ease of doing business with Buckeye. We hope you will take a moment to explore them.

    Please contact Provider Services at 866.296.8731 with any questions you may have.

    Buckeye Health Plan has Reduced Prior Authorization Requirements

    In response to your feedback, Buckeye has removed 154 servcies from our prior authorization list. View the full list (PDF) and review our Quick Reference Guides for more information on prior authorization and important contacts.

    Important Updates Effective January 1, 2020 - Allwell from Buckeye Health Plan

    Allwell from Buckeye Health Plan requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Allwell.

    Allwell from Buckeye Health Plan is committed to delivering cost effective quality care our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria. Please see the provider notice and list of procedures requiring prior authorization:

    • 2020 Provider Notification for Medicare Prior Authorization Updates (PDF)
    • List of Codes and Changes Effective January 1, 2020 (PDF)
    • PA List 2021 Part B Appendix A (PDF)

    Important Updates Effective September 3, 2019

    Buckeye Health Plan is pleased to announce its collaboration with New Century Health (NCH), an oncology quality management company, to implement a new oncology pre-approval program, Buckeye Health Plan Oncology Pathway Solutions. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.

    Beginning September 3, 2019, all oncology-related chemotherapeutic drugs and supportive agents will require clinical review by NCH before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests for all Buckeye Health Plans Medicaid members ages 18 and over. Please see the provider notice and accompanying handouts below:

    • Provider Notification Letter (PDF)
    • Provider FAQ Sheet (PDF)
    • List of Medications that Require Prior Authorization (PDF)

    Important Updates Effective August 15, 2019

    Buckeye Health Plan is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective August 15, 2019. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for BHP members undergoing Cardiac Surgical Procedures. Please see the provider notice and accompanying handout below:

    • Provider Notification Letter (PDF)
    • Prior Authorization Scope Coding Handout (PDF)

    Important Updates Effective January 1, 2019

    On January 1, 2019, prior authorization will be required for the below J codes in all care settings including inpatient hospital and outpatient hospital or ambulatory care center:

    • Fluocinolone acetonide, intravitreal implant, J7311
    • Fluocinolone acetonide intravitreal implant, J7313
    • Hyaluronan or derivative, gel-syn, J7328
    • Tacrol Envarsus xr, J7503
    • Netupitant palonosetron, J8655
    • Aldesleukin, J9015
    • Belinostat, J9032
    • Bendeka, J9034
    • Bortezomib, J9041
    • Cabazitaxel, J9043
    • Cyclophosphamide, J9070
    • Daratumumab, J9145
    • Leuprolide acetate implant, J9219
    • Olaratumab, J9285
    • Obinutuzumab, J9301
    • Ramucirumab, J9308
    • Temsirolimus, J9330
    • Pegloticase, J2507
    • Provider Notification of Prior Authorization Changes of DME (PDF)
    • Specialty Medication Prior Authorization Form (PDF)

    Important Updates Effective April 15, 2015

    Important Updates Effective November 1, 2014

    • Provider Notification of Prior Authorization Changes (PDF)
    • Cardiac Imaging Prior Authorization Changes Reference Guide (PDF)
    • Ordering Provider-Buckeye Cardiac Imaging Reference Guide (PDF)
    • Rendering Provider-Buckeye Cardiac Imaging Reference Guide (PDF)
    • Laboratory Prior Authorization Reference Guide (PDF)
    • Regional Laboratory Reference Guide for Prior Authorization (PDF)

    Update Posted December 18, 2012

    We know that recently you’ve been experiencing some issues with J9035 and J9355 authorizations and we apologize for any inconveniences this may have caused. Our goal is to continue to work with you to help ensure that you are able to provide your patients the best care possible.

    Effective, February 1, 2013, all participating Hematologists and Oncologists will be required to receive prior authorization before administering injectable drugs with costs over $250. If drugs are administered without authorization, the claim will be denied and the provider will not receive payment. There are some exceptions to this policy, so please call Provider Services to determine if a drug needs prior authorization.

    We are reviewing denials weekly for claims that have been denied due to the new authorization requirements and will override these denials until January 31.