MedicaidPrior AuthMedium impact
[Ohio] Avoid delays: LTC/custodial care authorization FAQs for MyCare Ohio care providers
Anthem BCBS·OH · Geriatrics, Palliative Care·Provider Bulletin
Effective date
Jun 1, 2026
We identified it
Jun 1, 2026
Summary
Anthem MyCare Ohio has published FAQs clarifying prior authorization requirements for long-term care and custodial care services. Key points: LTC/custodial care authorizations approved for January 1, 2026 will be automatically extended through year-end (provided complete documentation was submitted); no retro authorizations are permitted; assisted living per diem (T2031) requires prior authorization; and all requests must be submitted via Availity Essentials or fax with complete clinical documentation, PASRR, and LOC forms.
Action Required
Billing team and clinical staff should take the following actions: (1) Immediately update internal workflows to ensure all LTC/custodial care authorization requests include clinical documentation, PASRR, and LOC forms before submission via Availity Essentials or fax to 877-643-0671 to avoid delays; (2) By June 1, 2026 and ongoing: Verify that assisted living per diem claims using code T2031 have prior authorization before submission—claims submitted without authorization will be denied with no retro authorization option available; (3) For existing authorizations approved on or after January 1, 2026: Track these in the billing system and confirm extensions are processed by the health plan; if extension information is not received within 14 days of the authorization end date, proactively resubmit missing documentation; (4) Update staff training to clarify that MyCare Ohio does not allow retro authorizations—if a claim is denied for lack of prior auth, the practice must submit a claims dispute within required timeframe with clinical documentation and explanation of extenuating circumstances; (5) Educate providers that the Floor to SNF program does not apply to MyCare members, Carelon does not handle MyCare LTC authorizations (health plan handles them), and Single Case Agreements are not required for non-participating providers (but authorization is still mandatory). Failure to obtain prior authorization will result in claim denials that cannot be retroactively reversed.