MedicaidPrior AuthHigh impact
[Ohio] Level of Care and Prior Authorization Requirements for Medicaid Covered Nursing Facility (NF) Stays
CareSource·OH · Geriatrics, Critical Care, Pulmonology·Provider Bulletin
Effective date
May 5, 2025
We identified it
May 9, 2026
Summary
CareSource updated Level of Care (LOC) and Prior Authorization requirements for Ohio Medicaid nursing facility stays. MyCare Ohio members require a LOC determination; Medicaid Managed Care members require Prior Authorization (which includes LOC). Claims will be denied without current authorization. Additionally, nursing facilities on CMS Special Focus Facility lists or with one-star ratings are ineligible for ventilator reimbursement.
Action Required
Effective immediately (May 5, 2025): Billing team must implement dual submission pathways based on member plan type. For CareSource MyCare Ohio members: submit LOC requests via secure email (MyCareLTCAuthorizations@CareSource.com), fax (1-844-417-6157), or provider portal. For Medicaid Managed Care members: submit Prior Authorization via fax (1-888-752-0012), phone (1-800-488-0134), or mail. All requests must include member demographics, PASRR evidence, clinical documentation with ADL self-performance, current orders, therapy notes, and progress notes. Update internal workflows to flag all nursing facility admissions for authorization verification before claim submission. Implement system rules to automatically deny/hold claims for NF stays lacking current LOC or Prior Authorization. For ventilator services: verify facilities are not on CMS Special Focus Facility (Table A or D) or have one-star ratings before processing ventilator reimbursement claims; deny ventilator claims for ineligible facilities. Failure to obtain authorization prior to service delivery will result in claim denials.