MedicaidPrior AuthHigh impact
[Ohio] Avoid delays: LTC/custodial care authorization FAQs for MyCare Ohio care providers
Anthem BCBS·OH · Geriatrics, Palliative Care·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 7, 2026
Summary
Anthem MyCare Ohio has issued updated guidance on long-term care (LTC) and custodial care prior authorization requirements. Key clarifications include: authorizations approved for January 1, 2026 will be extended through year-end if all required information was submitted; assisted living per diem (T2031) requires prior authorization; no retroactive authorizations are permitted; and the Floor to SNF program does not apply to MyCare members. Billing teams must ensure all LTC/custodial care authorization requests include clinical documentation, PASRR, and Level of Care forms to avoid claim denials.
Action Required
Immediately: Billing team must verify all MyCare Ohio LTC/custodial care authorization requests submitted through Availity Essentials or fax (877-643-0671) include: (1) clinical documentation, (2) PASRR Level of Care (LOC) form, and (3) state authorization request form. Update billing software to flag incomplete submissions before sending to payer. For assisted living per diem claims using CPT T2031, require prior authorization in all cases. Stop attempting retro-authorizations for MyCare; instead, train team to submit claims disputes with clinical documentation and explanation of extenuating circumstances if authorization was missed. By July 13, 2026 (end of 14-day window): Contact Anthem authorization team immediately if any January 1, 2026 LTC authorizations have not been extended, as failure to provide missing information within 14 days will result in authorization termination. Update internal workflows to reflect that Floor to SNF program does NOT apply to MyCare members. Train billing staff that authorization status can be checked via Availity Essentials dashboard (standard requests process in up to 7 days; urgent requests within 48 hours). Failure to obtain proper prior authorization will result in claim denials.