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.
Prior authorization via fax
Inpatient authorization fax information
- Physical health: 877-643-0671
- Includes concurrent reviews for inpatient and admission request for skilled nursing facility, long term acute care, acute rehab, and nursing facilities
- Behavioral health: 866-577-2184
- Medicaid prior authorization: 800-964-3627
- Includes precertifications for elective admissions
Outpatient authorization fax information
- Physical health: 877-643-0672
- Includes home healthcare, high dollar imaging, physical therapy, occupational therapy, speech therapy, per diem nursing, durable medical equipment, chiropractic, and acupuncture
- Behavioral health: 866-577-2183
- Medical injectables: 800-563-5581
- Medicaid prior authorization: 800-964-3627
- Includes outpatient surgeries
Prior authorization requests and forms
- Services Requiring Prior Authorization
- Ohio Medicaid Managed Care Nursing Facility Request Form
- 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
- Standard Ohio Medicaid Nursing Facility 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.
Don’t have an Availity Essentials account?
Need help with Availity Essentials?
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
Call: 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.
Contact SPBM
Call: 833-491-0344
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
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:
- SPBM Phone: 833-491-0344 (TTY 711)
- SPBM Fax: 833-679-5491
- Online: Ohio Medicaid Pharmacy Services Website
Submitting and Checking Prior Authorization (PA) Requests for MyCare Ohio
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:
- Phone: 833-293-0661 (TTY 711)
- Fax: 1-844-521-6938
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:
- Phone: 833-727-2170 (TTY)
- Fax: 800-563-5581
- Online: Availity.com
Provider tools & resources
- Log in to Availity Essentials
- Launch Provider Learning Hub Now
- Learn about Availity
- Prior Authorization Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Provider Search Tool
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)