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Buckeye prior authorization form pdf

Buckeye prior auth form pdf 2025

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The document is a Prior Authorization Request Form that outlines the process for requesting prior authorization for various medical services, particularly out-of-network services. It includes sections for member information, referring provider details, service provider information, types of services requested, clinical information, and additional clinical details. The form emphasizes the importance of completeness to avoid delays and provides contact information for submission.

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Click ‘Get Form’ to open the buckeye prior auth form in our platform.
Begin by filling out the MEMBER INFORMATION section. Enter your name, ID number, date of birth, group number, address, and phone number clearly to avoid any delays.
Next, move to the REFERRING PROVIDER section. Input the provider's name, NPI number, phone number, TAX ID number, and indicate if they are a participating provider.
In the PROVIDER/FACILITY TO PERFORM SERVICE section, provide details about the facility performing the service. If it’s the same as above, check the box provided.
For TYPE OF SERVICE(S) REQUESTED, select all applicable services by checking the corresponding boxes. Ensure you review any specific requirements for out-of-network requests.
Fill in CLINICAL INFORMATION with procedure codes and diagnosis codes as required. This information is crucial for processing your request.
Complete ADDITIONAL CLINICAL INFORMATION by providing start and end dates along with frequency of services needed.
Finally, choose between STANDARD REVIEW or EXPEDITED REVIEW based on urgency and sign if necessary before submitting via fax or phone as indicated.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are prior authorization forms?

A prior authorization form will include information about you, your medical conditions, and your health care needs. Its important to fill out the form completely and accurately. Incomplete or incorrect information could delay your request or result in a denial.

Does Medicare use prior authorization?

Prior authorization is a requirement that a health care provider obtain approval from Medicare to provide a given service. Prior Authorization is about cost-savings, not care. Under Prior Authorization, benefits are only paid if the medical care has been pre-approved by Medicare.

Why does Medicaid require prior authorization?

Federal regulations allow Medicaid fee-for-service (FFS) programs and managed care organizations (MCOs) to use prior authorization to limit services in an effort to prevent unnecessary utilization and ensure quality of care ( 1902(a)(30) of the Social Security Act (the Act), 42 CFR 438.210).

Which types of procedures may need pre authorization under Medicaid?

For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.

Is Buckeye considered Medicaid?

Buckeye Health is a Medicaid plan for adults and children in Ohio. Eligibility is determined by family size and income.

buckeye prior authorization form

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What services typically require prior authorizations?

Services That Require Prior Authorization Diagnostic imaging (such as MRIs, CTs, and PET scans) Durable medical equipment (such as wheelchairs) Rehabilitation (like physical or occupational therapy) Home health services (such as nurses) Non-emergency surgery (elective surgery)

Does Medicaid use prior authorization?

States have authority over prior authorization practices in Medicaid and can implement prior authorization regulations that are stricter than federal requirements (Medicaid Health Plans of America (MHPA) 2023). Medicaid statute provides authority for utilization review in Medicaid ( 1902(a)(30) of the Act).

How do I verify eligibility for Buckeye Health Plan?

Providers are responsible for verifying eligibility every time a member is seen in the office. PCPs should also verify that a member is assigned to them. To verify enrollment call Buckeye Provider Services at 1-866-296-8731 or log on to Buckeyes Secure Provider Portal .