OH Medicaid

Hospital Utilization Management Program

Permedion provides the following services in support of the ODM’s Hospital Utilization Management Program:

  • Prior authorization for med-surg hospital, home health and behavioral health services
  • Pre-certification of psychiatric inpatient admissions
  • Retrospective hospital reviews, including inpatient psychiatric hospitalization
  • Focused reviews as determined by ODM for specific provider’s claims or medical records
  • Healthcare studies

Prior Authorization/ Precertification Resources

To access the current list of services and codes that require prior authorization/ precertification, please go to the Ohio Department of Medicaid provider fee schedule and rates, located:
https://medicaid.ohio.gov/provider/feescheduleandrates

Prior Authorization Form: Increased State Plan Home Health Services
Prior Authorization Provider Instructions: Increased State Plan Home Health Services
Nusinersen (Spinraza) Cover Letter
Nusinersen (Spinraza) Prior Authorization Form
Ohio Department of Medicaid Inpatient Psychiatric Precertification Form

CONTACTS

For questions, please contact:

  1. ODM Provider Helpline: 1-800-686-1516,
  2. Hospital Med-Surg Retrospective Reviews: SURS Department ODMSURS@medicaid.ohio.gov
  3. Appeals for Hospital Utilization Management Program (Permedion and SURS):
    • Mail: HMS, Attn: Ohio Medicaid Appeals, 5615 High Point Drive, Irving, TX 75038
    • Fax: Fax to 1-866-206-6861
    • DOTS: Contacts DOTSQuestions@hms.com for instructions and setup
  4. HMS Permedion:
    • Home Health Prior Authorization Submissions, Fax: 1-855-474-4306, ***Please note during the start-up beginning 12/1, current templates/form will be accepted***
    • Behavioral Health and Inpatient Psych Authorization Questions, Phone: 1-855-974-5393,
    • Medical-Surgical Hospital and Home Health Prior Authorization Questions, Phone: 1-800-772-2179
    • Email address for all provider contacts: ODMUR@gainwelltechnologies.com

 

Additional information will be distributed by ODM and posted to our website.

Ohio Medicaid Managed Care Entity External Medical Review

Beginning July 1, 2022, providers who disagree with Aetna Better Health's determination on appeal to deny, limit, reduce, suspend, or terminate a covered service with the OhioRISE program for lack of medical necessity may request an External Medical Review with Permedion. The request for External Medical Review must be submitted to Permedion within 30 calendar days of the written notification that the internal appeals process has been exhausted. Providers may also request an External Medical Review if the MCE has not met the required Provider Internal Appeal or Provider Claim Dispute resolution time frame for a denial based on medical necessity.

Providers must complete the “Ohio Medicaid MCE External Review Request” form and submit to Permedion together with the required supporting documentation. Upload this request form and supporting documentation to Permedion’s provider portal at https://ecenter.hmsy.com/ (new users will send their documentation through secured email at IMR@gainwelltechnologies.com to establish portal access). Providers should attach to this request form only additional documents not originally provided to the MCE during their review process.

For more information about the External Medical Review process, please contact Permedion at 1-800-473-0802, Option 2.