Prior Authorization (Part C)
What is Prior Authorization?
Prior authorization means that you must get approval from Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) before you can get a specific service or drug or see an out-of-network provider. Buckeye Health Plan – MyCare Ohio (Medicare-Medicaid Plan) may not cover the service or drug if you don’t get approval. If you need urgent or emergency care or out-of-area dialysis services, you don't need to get approval first.
Which services require Prior Authorization?
To get a list of services that require prior authorization, please contact Buckeye Health Plan – MyCare Ohio at 1-866-246-4359 (TTY: 711).
For out-of-network services you must get prior authorization. You do not need prior authorization for emergencies. Out-of-area urgent care or dialysis does not need prior authorization.
What is the process for getting Prior Authorization?
You may get prior authorization by calling Buckeye Health Plan – MyCare Ohio at 1-866-246-4359 (TTY: 711).
Providers need to send prior authorizations through the web portal, by phone or by fax.
You will be told if we approve the service within 72 hours after we get your request. This is what we call a Fast decision (Expedited).
You will be told no later than 14 calendar days for all other requests.
If we find that your health may be in danger we will expedite your request.
We will tell you what we decide in writing or by telephone. In the case of an emergency, you do not need prior authorization.
Prior authorization is not a promise of payment. The plan has the right to review the service for medical need after you receive the services. The member must be eligible for services. Some services have limits. Some benefits have exclusions.
Important Information About Your Appeal Rights
There are 2 kinds of appeals:
Standard Appeal – An appeal is the process to review a decision you may not like. The negative decision is called a coverage determination. If you do not like the choice we have made, you have the right to make an appeal. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal 15 calendar days after we hear your appeal (7 days for appeals related to medications).
If you had to pay for services and want to be paid back, you can ask us. If your appeal is to pay you back, we will tell you in writing. We will tell you in 15 calendar days.
Fast Appeal – You will get an answer within 72 hours after we get your appeal.
You can ask for a fast appeal if you or your doctor think your health could be in danger.
If your doctor asks for a fast appeal, you will get one.
If you want a fast appeal but your doctor did not ask, we may not approve it. If we don’t give you a fast appeal, we’ll give you an answer within 15 days (or 7 days for drug appeals).
How to ask for an appeal with Buckeye
Step 1:
To ask for an appeal you have to tell us. It can be from you, your representative, or your doctor. Your appeal request must include:
- Your name
- Address
- Member number
- Reasons for appealing
- Other information that shows why you need the item or service. Call your doctor if you need this information.
You can ask to see the medical records and other documents we used to make our decision before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.
Step 2:
Write, mail, FAX, deliver your appeal or call us.
For a Standard Appeal:
Buckeye Health Plan
ATTN: Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105
Phone: 1-866-549-8289 (TTY: 711)
FAX: 1-844-273-2671
If you ask for an appeal by phone, we will send you a letter confirming what you told us.
For a Fast Appeal:
Phone: 1-866-549-8289 (TTY: 711)
FAX: 1-844-273-2671