Pre-Service Provider Appeals

A pre-service appeal is the request for review per a Notice of Adverse Action. 

A Notice of Adverse Action is the denial or limited authorization of a requested service, including the:

• Type or level of service
• Reduction, suspension, or termination of a previously authorized service
• Denial, in whole or part of payment for a service excluding technical reasons
• Failure to render a decision within the required timeframes
• Denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Buckeye Health Plan network

Time Limit for Provider to Request

The appeal review may be requested in writing or verbally within 60 calendar days from date of the Notice of Adverse Action. Members may request Buckeye to review the Notice of Adverse Action to verify if the right decision has been made.

Resolution Timeframes

• Standard appeal decisions are issued within 10 calendar days from date of receipt of the appeal request.
  
  
• Expedited appeal decisions are issued as expeditiously as the member’s health condition requires, to not exceed 48 hours from the initial receipt of the appeal.
  • Expediting pre-service appeal is when either Buckeye Health Plan or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. If the request for expedited appeal is denied, the appeal must be transferred to the timeframe for standard appeal resolution.  

• 14 Calendar Day Extension may be added by Buckeye is applied for both standard and expedited pre-service appeals:
  • If the member requests the extension, or
  • If Buckeye provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest.
  • For any extension not requested by the member:
    • Buckeye will provide written notice of the reason for delay to the member.
    • Buckeye will make reasonable efforts to provide the member with prompt verbal notice of any decisions not resolved wholly in favor of the member and will follow-up in writing within two calendar days of action.

Who Can File a Pre-Service Appeal

• For pre-service member appeals, members or an authorized representative of a member may appeal an adverse determination. This can be the member, doctor, or other service provider like a physical therapist. Written consent is required if provider is appealing on behalf of the member or assisting member in the appeals process. If you are assisting a member to file a pre-service appeal, please go to Appointing a Representative.
• For additional information on pre-service member appeals, please go to our Member Page. 
• A practitioner with knowledge of the member’s condition may request an expedited appeal on a member’s behalf. Written member consent is not required for expedited appeals requested by the provider. Providers may also submit a request for an expedited appeal by phone or fax.
• For pre-service provider appeals, requesting providers can appeal on their own behalf without written consent from the member.

How to Submit Provider Pre-Service Appeals

Provider pre-service appeals can be submitted to Buckeye Health Plan through the following methods:

• Online: Access the portal via our Provider Home Page
  (This is the most efficient method. Please see below for the portal filing instructions for pre-service appeals.)
• Phone: 866-246-4358 (TTY: 711)
• Fax: 866-719-5404
• Mail:
  Buckeye Health Plan
  4349 Easton Way, Suite 120
  Columbus, OH 43219

Provider Portal Filing Instructions for Pre-Service Appeals

1. From our Provider Home Page, login to Provider Portal.
   • New users can create new account to establish portal access. Go to the Create Account page.
2. Select the appropriate Plan Type (Medicaid) and TIN Number.
3. Find an eligible member, select authorizations by clicking on the Authorizations tab from the top header of the page or the members overview page.
   • Authorization page will show a list of authorizations for that member with different status (Example: Approve / Pended / Deny).
   • Authorization Appeal cannot be created for Pending Authorizations.
4. Click on an authorization number to show the Authorization details page which displays:
   • Details of the authorization
   • List of appeals created for the same authorization number at the bottom of the page along with its status type and other details. Clicking on the ‘Request ID’ of the appeal will show details of the appeal along with its status.
   • ‘Request Appeal’ button to create a new appeal.
5. Click the “Request Appeal” button to display an Appeal Request form.
6. On the Appeal Request Form, all fields must be completed.
   • Field ‘Appeal type’ requires either Medical or Administrative or both to be selected.Rationale is required and has a limit of 2000 characters.Documents must be attached using the “Evidence Materials and Attachment” section.
   • After all required fields are completed, click the “Save & Review Appeal” button at the bottom to review all appeal information are correct before submission.
   • Select the “Send Request” button at the bottom of the review page. On successful submission, users will be redirected back to the Authorization details page with new appeal being added to the list.
7. To view the status of your submission, click on the appeal reference number (Request ID) on the Authorization details screen to display Appeal details page.
8. Select the “Send Request” button at the bottom of the review page. On successful submission, users will be redirected back to the Authorization details page with new appeal being added to the list.
9. To view the status of your submission, click on the appeal reference number (Request ID) on the Authorization details screen to display Appeal details page.

If you have questions, please contact Provider Services at 866-296-8731.