[Ohio] Documentation updates for acute rehab, SNF, DME, HH, and PDN — effective

By April 1, 2026: Billing team must implement the following changes to prior authorization submission processes: ACUTE REHABILITATION: Ensure all initial acute rehab prior auth requests include preadmission screening (PAS) documentation containing: level of function before event, condition causing need, expected improvement level, expected timeframe, risk for complications, combination of treatments needed, and anticipated discharge destination. PM&R notes are recommended. NURSING FACILITIES: Obtain and submit with every prior auth request: (1) completed PASRR document, (2) Ohio Medicaid Managed Care/Anthem MyCare Ohio nursing facility request form, and (3) all supporting documentation. Reference the Nursing Facility Quick Reference Guide for additional guidance. DME: Require Certificate of Medical Necessity (CMN) for all DME prior auth requests using appropriate ODM forms (use ODM 01913 for requests lacking specific CMN). Verify CMNs are completed accurately, legibly, signed, and dated. Note: CMN remains valid despite Medicaid eligibility category changes. HOME HEALTH (HH): Require completed, current signed plan of care, provider order, and supporting documentation. For post-hospital HH: require ODM 07137 Section II establishing institutional level of care. For non-post-hospital HH: ODM 07137 is optional. Face-to-face encounter required within 90 days before or 30 days after start-of-care (not required for recertification). PRIVATE DUTY NURSING (PDN): For post-hospital PDN: require ODM 07137 Section III documenting need for skilled nursing at least 4 hours per day related to post-admission care. For maintenance PDN: require ODM 02374 plus face-to-face encounter. Face-to-face encounter required within 90 days before or 30 days after start-of-care. ACTION STEPS: (1) Update billing system prior auth workflows to require these specific forms and documentation elements; (2) Create/update provider submission checklists for each service type; (3) Train billing staff on new requirements; (4) Add documentation reminders to encounter forms; (5) Establish validation process to confirm all required documentation is present before submission. Contact Provider Relationship Account Management at 844-912-1226 or OHMedicaidENCPESupport@anthem.com with questions. Failure to submit complete documentation will result in processing delays and claim denials.