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Specialty Resources

Buckeye Health Plan has contracted with Evolent (previously NIA) for radiology benefit management.

The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Buckeye Health Plan oversees the Evolent program and is responsible for claims adjudication. Evolent manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.

Prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA/CCTA
  • MRI/MRA
  • PET Scan

KEY PROVISION:

Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Go to the Evolent website for more information.

Resources: 

Non-Emergent MSK Procedures

Effective January 1, 2024, Buckeye Health Plan is expanding our prior authorization program to include non-emergent MSK procedures. The expansion includes inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Buckeye Health Plan members.

We are partnering with Evolent for utilization management services for non-emergent, Medical Specialty Solutions. In consideration of the aforementioned agreement, Buckeye Health Plan will terminate its current MSK program and utilization management efforts with TurningPoint as of December 31, 2023.

Under the terms of the agreement between Buckeye Health Plan and Evolent, Buckeye Health Plan will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. Evolent will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Buckeye Health Plan.

Providers may begin contacting Evolent on January 1, 2024, to seek prior authorization for procedures scheduled on or after January 1, 2024.

FYI: Effective 1/1/2024 you will submit prior authorization requests to Evolent for dates of service 1/1/2024 and forward. You can submit prior authorization requests up to 12/31/2023 to TurningPoint.  

MSK Program (PDF)

2024 Spine Surgery Utilization Review Matrix (PDF)

2024 Joint Surgery Utilization Review Matrix (PDF)

MSK Surgery - Hip-Knee-Shoulder-Lumbar-Cervical Program FAQs (PDF)

To obtain prior authorizations:

Medicaid: 1-800-642-6551

Medicare/MMP: 1-800-424-4158 

Ambetter from Buckeye (Exchange): 1-800-424-4915

How to file an Evolent appeal 

Medicaid

Providers can request an appeal in writing or by calling the number below within sixty (60) days of the denial letter date.

Appeal rights include, the right to review the contents of the case file and to submit additional records or information. Appeals can be requested by writing or by calling us.

You can file an appeal by the following methods:

  • Phone: 1-866-972-9842 (must also send a written, signed appeal)
  • Fax: 1-888-656-0701
  • Letter via postal mail to:

Evolent
Attn: Appeals Department
P.O. Box 1495
Maryland Heights, MO 63043

The written appeal should include the following information:

  • Provider name
  • Member number
  • Provider phone number
  • Why you think we should change the decision
  • Medical information to support the request

You will be notified of a decision:

  • Service not complete: within ten (10) calendar days of your appeal request.
  • Service complete: within thirty (30) calendar days of your appeal request.

Expedited Appeal:

If you believe that waiting up to 30 calendar days for a decision could seriously risk the patient’s life or health, including being able to reach, keep, or get back to maximum function, tell us when asking for an appeal. If we agree, we will make a decision within 72 hours of receiving the request. An expedited appeal may be filed orally. It does not have to be filed in writing.

 

Ambetter/Exchange

Providers can request an appeal in writing or by calling the number below within one hundred eighty (180) days of the denial letter date.

Appeal rights include, the right to review the contents of the case file and to submit additional records or information. Appeals can be requested by writing or by calling us.

You can file an appeal by the following methods:

  • Phone: 1-866-972-9842 (must also send a written, signed appeal)
  • Fax: 1-888-656-0701
  • Letter via postal mail to:

Evolent
Attn: Appeals Department
P.O. Box 1495
Maryland Heights, MO 63043

The written appeal should include the following information:

  • Provider name
  • Member number
  • Provider phone number
  • Why you think we should change the decision
  • Medical information to support the request

You will be notified of a decision:

  • Service not complete: within thirty (30) calendar days of your appeal request.
  • Service complete: within sixty (60) calendar days of your appeal request.

Expedited Appeal:

If you believe that waiting up to 30 calendar days for a decision could seriously risk the patient’s life or health, including being able to reach, keep, or get back to maximum function, tell us when asking for an appeal. If we agree, we will make a decision within 72 hours of receiving the request. An expedited appeal may be filed orally. It does not have to be filed in writing.

Evolent Oncology Pathway Solutions

Buckeye Health Plan is pleased to announce its collaboration with Evolent (previously New Century Health), an oncology quality management company, to implement a new oncology pre-approval program, Buckeye Health Plan Oncology Pathway Solutions. The program will simplify the administrative process for providers to support the effective delivery of quality patient care.

Beginning September 3, 2019, all oncology-related chemotherapeutic drugs and supportive agents will require clinical review by Evolent before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests for all Buckeye Health Plan Medicaid members ages 18 and over.

Buckeye Health Plan Oncology Pathway Solutions program benefits include:

  • The use of clinical criteria, based on nationally-recognized guidelines, to promote evidence-based cancer care.
  • Increased collaboration with physician offices to foster a team approach.
  • Peer-to-peer discussions with medical oncologists who can understand and better discuss treatment plans.
  • A provider web portal Evolent.com to:
    • Obtain real-time approvals when selecting
      evidence-based Evolent treatment care pathways.
    • Determine which clinical documentation is necessary for medical necessity review.
    • View all submitted requests for authorization in one location.
    • Check member eligibility.

Pre-approval Process

  • The requesting physician must complete an authorization request using one of the following methods:
    • Logging into the Evolent.com Provider Web Portal
    • Calling 1-888-999-7713, Option 1, Monday–Friday (8 a.m. - 8 p.m. ET)

Timeframe for Approval

Real-time approval is given for Evolent recommended treatments. Timeframes for authorization of treatment regimens not auto approved by Evolent are as follows: Medicaid requests:

  • Pharmacy: 24 hours
  • Office Administered: 48 hours for expedited requests and 10 days for standard requests

Evolent may approve chemotherapeutic and supporting agents, including hematology drugs, for a period up to 90 days.

Authorizations issued by Buckeye Health Plan or Envolve Pharmacy Solutions before September 3, 2019 are effective until the authorization end date. Subsequent authorization requests must be submitted to Evolent. If continued authorization is not obtained from Evolent, drug-related claims may be denied.

Please note:

  • Inpatient requests for chemotherapy should continue to be submitted via Buckeye’s Secure Provider Portal 
  • Inpatient requests for chemotherapy may also be submitted via Buckeye’s Secure Fax at 1-866­-529-0291
  • Pharmacy dispensed chemotherapeutic and supportive agents that were previously submitted to
    Envolve Pharmacy Solution to Evolent
  • Failure to obtain prior authorization may result in denial of payment.

An Evolent representative will contact you soon to schedule an introductory meeting and training. Should you have any questions prior to the introductory meeting, please call Evolent at 1-888-999-7713, Option 6. You may also contact Buckeye Health Plan at 1-866-296-8731.

Please see below for find a list of medications that will need prior authorization for the medical benefit starting 9/3/19. There will be no changes to the pharmacy benefit. For pharmacy benefit questions, please refer to Buckeye Health Plan's preferred drug list. 

Please note any request using a generic J code (examples: J3490, J8499, J9999) will need a single case agreement to ensure proper payment. We look forward to offering you this program and hope that it will enhance your experience with oncology service authorizations.

TurningPoint - Surgical Quality and Safety Management Program

Buckeye Health Plan (BHP) is pleased to announce the launch of a new and innovative Surgical Quality and Safety Management Program, effective August 15, 2019. The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for BHP members undergoing Cardiac Surgical Procedures.

Program Highlights Include:

  • Administrative Tools to support an efficient, user friendly authorization process for procedures requiring precertification, in addition to recommended medical necessity determinations for procedures which do not require precertification. Easy and efficient post-procedural documentation submission which will be shared
    with BHP to facilitate timely claims payment.
  • Specialized “Peer to Peer” Engagement where a TurningPoint physician (from the same specialty) engages the provider regarding authorization requests that require additional clinical discussion to validate the clinical appropriateness of the procedure specific to the patient’s needs and current condition.
  • Clinical Support Tools to assist in the tracking and monitoring of patient outcomes and education around patient risks and preventive measures to better coordinate care for the member and reduce infection rates and complications due to patient comorbidities.
  • Reporting, and Analytics that gives Physicians and practice administrators greater visibility and transparency into their performance compared to the practice as a whole, as well as the rest of the market.
  • FDA Recall Tracking and Monitoring to facilitate timely and consistent notification to the Physician, patient, and to BHP when a member has received or needs a revision surgery due to a Class I or II FDA device recall.

This correspondence serves as notice under your Participating Buckeye Community Health Plan Provider Agreement of these program changes, effective August 15, 2019. TurningPoint will begin accepting prior authorization requests for these procedures beginning August 1, 2019 for dates of service August 15, 2019 or later.

The program will include the followingBuckeye Health Plan Membership: Medicaid, Ambetter, Allwell and MyCareOhio (Opt-In) Members.

Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC. and will be required for the following surgical procedures in both inpatient and outpatient settings:

  • Cardiac
    • AICD/ICD
    • Leadless Pacemaker
    • Pacemaker
    • Revision or replacement of ICD or Pacemaker
    • CABG (non-emergent only)
    • Coronary Angioplasty & Stents
    • Non-Coronary Angioplasty & Stents

TurningPoint's Utilization Management & Precertification Contact Information:

Key Provisions:

  • Emergency Related Procedures do not require authorization
  • It is the responsibility of the ordering physician to obtain authorization
  • Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claims.
  • Prior Authorization Scope Coding Handout (PDF)

We appreciate your support and look forward to your cooperation in assuring that Buckeye Health Plan members receive high quality cost-effective care for these surgical procedures.

Should you have any questions at this time, please contact Buckeye Health Plan Provider Services at (866) 296-8731.