Prior authorization requirements

Providers will have the choice of using either Availity Essentials* or fax to submit prior authorization requests for all medical (non-pharmacy) services. Providers may also use Availity Essentials to check the status of a prior authorization request.

Ohio Prior authorization via fax

 

Ohio Medicaid Plan

 

Inpatient authorization fax information – Ohio Medicaid

  • Ohio Medicaid – Inpatient Physical health: 877-643-0671
    • Inpatient Physical health includes concurrent reviews for inpatient and admission requests for skilled nursing facility, long-term acute care (LTAC), acute rehab, and nursing facilities
  • Ohio Medicaid – Elective admission: 800-964-3627
  • Behavioral health: 866-577-2184

 

Outpatient authorization fax information – Ohio Medicaid

  • Ohio Medicaid – Outpatient Physical health: 877-643-0672
    • Outpatient Physical health includes home healthcare, high-dollar imaging, physical therapy, occupational therapy, speech therapy, private duty nursing, durable medical equipment, chiropractic, and acupuncture
  • Ohio Medicaid – Medical injectables: 800-563-5581
  • Ohio Medicaid – Outpatient surgery and Elective admission: 800-964-3627
  • Behavioral health: 866-577-2183

 

MyCare Ohio for MyCare Medicaid Only and MyCare Dual Benefit

 

Inpatient authorization fax information – MyCare Ohio

  • Inpatient Physical health: Includes concurrent reviews for inpatient and admission requests for skilled nursing facility, long-term acute care (LTAC), acute rehab, and nursing facilities
    • MyCare Medicaid only – Inpatient Physical health: 877-423-9972
    • MyCare Dual Benefit – Inpatient Physical health: 877-423-9972
  • Inpatient Elective admissions
    • MyCare Medicaid only – Elective admissions: 800-964-3627
    • MyCare Dual Benefit – Elective admissions: 866-959-1537
  • Behavioral health: 866-577-2184

Outpatient authorization fax information – MyCare Ohio

  • Outpatient Physical health: Includes health home healthcare, high-dollar imaging, physical therapy, occupational therapy, speech therapy, private duty nursing, durable medical equipment, chiropractic, and acupuncture
    • MyCare Medicaid only – Outpatient Physical health: 877-643-0672
    • MyCare Dual Benefit – Outpatient Physical health: 866-959-1537
  • Outpatient surgery and elective admissions
    • MyCare Medicaid only – Outpatient surgery and elective admission: 800-964-3627
    • MyCare Dual Benefit – Outpatient surgery and elective admission: 866-959-1537
  • Behavioral health: 866-577-2183
  • Medical injectables: 800-563-5581

 

Prior authorization requests and forms

 

Prior authorization lookup tool 

 

Prior authorization forms 

 

Ohio Medicaid Managed Care Nursing Facility Request Form 

 

 Services Requiring Prior Authorization

 

 Substance Use Disorder Services Prior Authorization Form

 

 Uniform Prior Authorization Form 2023

 

 Urine Drug Testing Prior Authorization Form

 

 Floor to skilled nursing facility (SNF) provider process

How to check prior authorization status with Availity Essentials

 

To check the status of a prior authorization request or decision for a particular plan member, or to submit a clinical appeal, providers will access our Interactive Care Reviewer (ICR) tool via Availity Essentials. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.

Log in to Availity Essentials

Don’t have an Availity Essentials account?

 

Register free now 

 

Need help with Availity Essentials?

 

Learn more 

Medicaid Provider Resources

 

OhioRISE

 

OhioRISE (Resilience through Integrated Systems and Excellence) is a specialized managed care program for youth with behavioral health and multi-system needs. Aetna Better Health of Ohio will serve as the single statewide specialized managed care plan. For more information on OhioRISE, call their toll-free number, contact your provider services representative, or visit their site at AetnaBetterHealth.com/OhioRISE, or via phone.

 

Contact OhioRISE

 

 833-711-0773

 

 

Single pharmacy benefit manager (SPBM) for Medicaid providers

 

The SPBM provides more pharmacy choices for members and offers a more streamlined process for providers with a single preferred drug list and uniform clinical criteria for coverage. SPBM services include:

 

  • Processing pharmacy claims
  • Provide expert clinical knowledge to establish Preferred Drug Lists (PDLs)
  • Contract with pharmacies to ensure members have easier access to medications

 

For more information about the SPBM, call their phone number, contact your Provider Services representative, refer to your provider manual, or visit the Ohio Department of Medicaid's site.

 

Learn more about the SPBM 

 

Contact SPBM

 

 833-491-0344

MyCare Ohio Provider Resources

 

Coming soon.

Pharmacy

 

For information about pharmacy related prior authorizations, you may call directly, contact your Provider Services representative, refer to your provider manual, or submit your request online.

 

Submitting and Checking Prior Authorization (PA) Requests for Ohio Medicaid Plans

 

Pharmacy benefits for enrolled members are managed through the Ohio Department of Medicaid (ODM). ODM has contracted with a single pharmacy benefit manager (SPBM) to improve the administration of pharmacy benefits for managed care recipients and ensure transparency, accountability, and integrity to better serve Ohio Medicaid members and their healthcare providers.

 

Authorization inquiries, prior authorization and notification requests for Medicaid can be made through one of these options:

 

 

Submitting and Checking Prior Authorization (PA) Requests for MyCare Ohio Plans

 

Providers can submit prior authorization (PA) or coverage determination requests for MyCare Ohio members electronically, by phone, or by fax.

 

Electronic Prior Authorization (ePA)
 

Providers can submit requests by logging into the CarelonRx Provider Portal or by submitting the request to CoverMyMeds® or Surescripts® . These tools allow providers to:

  • Submit required clinical documentation online
  • View updates on the status of requests

 

 

Phone or Fax Options
 

Requests and inquiries can also be made by:

 

 

Information Needed to Check a PA Status
 

When checking the status of a PA request, providers should have:

  • Patient/member ID number
  • Prescription drug name
  • Prescriber information
  • Date the PA request was submitted

 

 

Medical injectables for Medicaid providers
 

Authorization inquiries, prior authorization and notification requests for medical injectables can be made through one of these options:

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