[Ohio] Medicaid: New PA documentation for rehabilitation, SNF, DME, HH/PDN — avoid delays

By April 30, 2026: Billing team must implement the following changes to avoid claim denials and processing delays: ACUTE REHABILITATION: - Update prior authorization submission requirements in billing system to mandate inclusion of: preadmission screening (PAS) with level of function, causative condition, expected improvement, timeline, complication risk, treatment combination, and discharge destination - Recommend PM&R physician notes be included with all acute rehab PA requests NURSING FACILITY: - Update PA submission checklists to require: completed PASRR form and Ohio Medicaid Managed Care/Anthem MyCare Ohio nursing facility request form with every PA request and extension - Add reminder to include all supporting documentation - Reference Nursing Facility Quick Reference Guide in submission procedures DME: - Update PA submission process to require certificate of medical necessity (CMN) or equivalent documentation - Ensure billing team knows to use form ODM 01913 for DME requests lacking specific CMN - Include all pertinent supporting documentation with submissions HOME HEALTH & PRIVATE DUTY NURSING: - Update PA templates to require correct ODM forms: ODM 07137 (Section II for post-hospital HH, Section I for non-post-hospital/continuation HH, Section III for post-hospital PDN) or ODM 02374 (Section III for maintenance PDN) - Ensure provider signature, credentials, and date are documented on all forms - Verify face-to-face encounter occurred within 90 days before or 30 days after start of care (may be via telehealth) - Include provider order and all pertinent supporting documentation ACTIONS FOR ALL SERVICE TYPES: - Billing team: Update prior authorization submission checklists in billing system and internal procedures - Providers: Educate on new documentation requirements; add reminders to encounter forms and order templates - Front desk: Ensure all required documentation is collected before PA submission - For questions: Contact Anthem Provider Relationship Account Management at 844-912-1226 or OHMedicaidENCPESupport@anthem.com CONSEQUENCES: Claims will be denied or delayed if required documentation is not submitted with PA requests.