The Prior Authorization/Prospective Review Area
The Prior Authorization/Prospective Review Area ensures that all Medicaid services requiring prior authorization are medically necessary and appropriate; evaluates and prices (when necessary) PA requests for medical, transportation, durable medical equipment, organ transplantation, supplies, and dental and vision services.
Ohio Medicaid providers may contact the Interactive Voice Response (IVR) system for billing concerns. The IVR is available 24-hours, seven-days a week. Call 1-800-686-1516.
Notice Regarding Incontinence Garments
Effective January 1, 2010, the Medicaid Durable Medical Equipment benefit coverage of incontinence garments (disposable diapers, liners and underwear/pull-ups and diaper service including T4521-T4535 and T4538) for adults changed from 300 per month to 200 a month. Please note that incontinence codes T4535 and T4538 are also subject to these parameter changes and that clarifying revisions to the Medicaid Supply List OAC rule 5101:3-10-03 will be updated at the earliest opportunity.
Do not submit PA requests before checking the warranty for covered repairs on wheelchair repairs. Medicaid cannot reimburse providers for warranty-covered wheelchair repairs. Maintain HIPAA compliance, by always referring to NAS PDAC when selecting codes for all DME. The use of incorrect codes will result in denials.
When requesting enteral nutrition products remember:
- One unit equals 100 calories, and
- Deduct the amount provided by the Women, Infants, and Children (WIC) Program
- Use miscellaneous codes (e.g., E1399, K0108) for unique items when there is no applicable or available HCPCS code
PA Turnaround Time
PA requests are reviewed according to the date received in the Initial (or PA Review) Queue. The turnaround time is improved when submitted supporting documentation (Certificate of Medical Necessity) is accurately completed, legible, and signed and dated by the appropriate medical professional(s).
Do not submit duplicate PA requests. Submitting duplicate requests will delay turnaround time.