MedicaidPrior AuthHigh impact
[Ohio] Updating guidance for prior authorization documentation
Anthem BCBS·OH · Physical Therapy, Occupational Therapy, Speech Therapy +2 more·Provider Bulletin
Effective date
May 1, 2026
We identified it
Jun 5, 2026
Summary
Ohio Medicaid/MyCare Ohio updated prior authorization documentation requirements effective May 1, 2026 for acute rehabilitation, nursing facility, DME, home health, and private duty nursing services. Billing teams must now ensure specific documentation (preadmission screenings, PASRR forms, certificates of medical necessity, face-to-face encounters, and care provider orders) accompany all PA requests to avoid processing delays or claim denials.
Action Required
By May 1, 2026: Billing team must implement updated prior authorization submission requirements across all affected service lines. SPECIFIC ACTIONS: (1) Acute Rehabilitation PA - Require preadmission screening (PAS) with all initial requests including level of function, causative condition, expected improvement, timeline, complication risks, treatment combinations, and discharge destination; add physical medicine & rehabilitation notes when available. (2) Nursing Facility PA - Require PASRR document and Ohio Medicaid Managed Care/Anthem MyCare Ohio nursing facility request form with every PA request; include all supporting documentation. (3) DME PA - Require Certificate of Medical Necessity (CMN) or equivalent documentation (use form ODM 01913 if no specific CMN available) with all PA requests. (4) Home Health/PDN PA and Claims - Require care provider order; ensure face-to-face encounter within 90 days prior to or 30 days after SOC documented on ODM 07137 or compliant signed POC; submit initial RN/therapist assessment within 48 hours and comprehensive assessment within 5 days of SOC; establish POC at SOC with service specifics; require OASIS at SOC, recertification, significant change, transfer, and discharge (submit electronically within 30 days); require electronic visit verification for all home health billing. (5) PDN-Specific - Use ODM 07137 Section III for post-hospital PDN (must support ≥4 hours/day skilled nursing need); use ODM 02374 Section III for maintenance PDN with required face-to-face. Update billing software to enforce these requirements; modify PA submission workflows and provider order templates; train billing and clinical staff on new documentation standards; communicate requirements to providers. Providers must include provider signature, credentials, and dates on all required forms. Consequences: Claims lacking required documentation will be denied and processing will be delayed. Contact Provider Relationship Account Management at 844-912-1226 or OHMedicaidENCPESupport@anthem.com for questions.