Prior Authorization Rules for Medical Benefits
What is Prior Authorization?
Prior Authorization is a request made by you or your doctor to get Buckeye Health Plan approval before receiving treatment. During this process, we may request and review medical records, test results and other information so that we understand what services are being performed and also to determine if the services requested are medically necessary.
What services require Prior Authorization?
To obtain a list of services that require prior authorization, please contact Buckeye Health Plan at 1-866-389-7690 (TTY: 711). Please note that all out of network requests require prior authorization except emergency care, out-of area urgent care, or out-of area dialysis.
What is the process for obtaining a Prior Authorization?
You may request prior authorization by calling Buckeye Health Plan at 1-866-389-7690 (TTY: 711). We recommend that providers submit prior authorizations through the web portal, via phone or via fax.
Decision and notification will be made no later than 72 hours after receipt for requests meeting the definition of Expedited (fast decision) and no later than 14 calendar days for requests meeting the definition for Standard. Buckeye Health Plan automatically expedites an organization determination if Buckeye Health Plan finds that your health, life, or ability to regain maximum function may be jeopardized by waiting for a standard determination. We will notify you of our decision either in writing or via telephone. In the case of an emergency, you do not need prior authorization.
Prior authorization is not a guarantee of payment. Buckeye Health Plan retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.
Last Updated: 10112016