Provider Toolkit: Prior Authorization Guide

PHONE
1-877-687-1189
After normal business hours and on holidays, calls are directed to the plan’s 24-hour nurse advice line. Notification of authorization will be returned by phone, fax or web.

1. Emergency services DO NOT require prior authorization.
2. All out-of-network services and providers DO require prior authorization
3. Failure to complete the required authorization or notification may result in a denied claim.

Services and Procedures Requiring Prior Authorization

THE FOLLOWING LIST IS NOT ALL-INCLUSIVE

• Air ambulance transport (non-emergent fixed wing airplane)
• Durable Medical Equipment (DME)
• Home healthcare services
• Hospice
• Furnished medical supplies
• Orthotics/prosthetics
• Genetic testing
• Quantitative urine drug screen

• Reconstructive surgery
• Experimental or investigational
• High Tech Imaging administered by NIA (CT, MRI, PET):
  • Submit requests to RadMD.com
  • All inpatient admissions (within 1 business day of admission)
  • Observation stays exceeding 48 hours
    • Notification is required within 1 business day if admitted

    All elective/scheduled admission notifications requested at least 5 days prior to the scheduled date of admit including but not limited to:

    • Medical admissions
    • Surgical admissions
    • Hospice care
    • Rehabilitation facilities

    

    
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    Ambetter from Buckeye Health Plan is underwritten by Buckeye Community Health Plan, Inc. which is a Qualified Health Plan issuer in the Ohio Health Insurance Marketplace. This is a solicitation for insurance. ©2024 Buckeye Community Health Plan, Inc., Ambetter.BuckeyeHealthPlan.com. If you, or someone you’re helping, have que

    Ambetter from Buckeye Health Plan is underwritten by Buckeye Community Health Plan, Inc. which is a Qualified Health Plan issuer in the Ohio Health Insurance Marketplace. This is a solicitation for insurance. ©2024 Buckeye Community Health Plan, Inc., Ambetter.BuckeyeHealthPlan.com. If you, or someone you’re helping, have questions about Ambetter from Buckeye Health Plan, and are not proficient in English, you have the right to get help and information in your language at no cost and in a timely manner. If you, or someone you’re helping, have an auditory and/or visual condition that impedes communication, you have the right to receive auxiliary aids and services at no cost and in a timely manner. To receive translation or auxiliary services, please contact Member Services at 1-877-687-1189 (TTY 1-877-941-9236). For more information on your right to receive an Ambetter from Buckeye Health Plan free of discrimination, or your right to receive language, auditory and/or visual assistance services, please visit AmbetterHealth.com and scroll to the bottom of the page.