[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287543-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-287543-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","ohio-medicaid-authorization-form-managed-care-entity-contact-information","Ohio Medicaid Authorization Form - Managed Care Entity Contact Information","","Ohio Medicaid Authorization Form for Community Behavioral Health gathers managed care entity and member details, including request type, service request urgency, member identifiers, and provider/billing agency information. The form includes structured selection of behavioral health service categories such as ACT, MRSS stabilization, testing, SBIRT, diagnostic evaluation, assessments, peer support, partial hospitalization, and other services, with start dates and units/visits fields. It also provides guidance for submitting substance use disorder residential treatment and partial hospitalization prior authorization requests with required clinical documentation, diagnoses, history, risk information, treatment plans, and updates for continued stays.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/ohio-medicaid-authorization-form-managed-care-entity-contact-information/287543/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/ohio-medicaid-authorization-form-managed-care-entity-contact-information/287543.png","ImageObject",442,249,{"name":42,"@type":43},"Pentious","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What information does the Ohio Medicaid Authorization Form request from the managed care entity and member?","Question",{"text":62,"@type":63},"It requests managed care entity contact selections, request type (initial or concurrent), service request type (routine or expedited/urgent), member name, date of birth, phone number, and Medicaid ID, plus date of request.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Which provider and billing fields are included in the form?",{"text":67,"@type":63},"The form includes billing provider/agency name and service location, provider contact name, provider NPI, tax ID, phone and fax numbers, Medicaid provider number, and provider status (MCE contracted or non-contracted).",{"name":69,"@type":60,"acceptedAnswer":70},"What must be submitted for SUD residential treatment and partial hospitalization service requests?",{"text":71,"@type":63},"Requests for specific SUD services should use the ODM 10276 prior authorization form and include service start date and referral source with reason, attach clinical documentation for justification, provide primary/secondary diagnoses and psychosocial issues, include medical and behavioral health history with risk considerations, and include a treatment plan and discharge plan, with updates for continued stay requests.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},287543,1789632455,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":4},1374404730887,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Ohio Medicaid Authorization FormCommunity Behavioral Health  \nManaged Care Entity Contact Information:  \n\n| Member Information |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Managed Care Entity (MCE)\u003Cbr>☐ Medicaid Managed Care ☐ MyCare Ohio ☐ OhioRISE |  |  | Date of Request (mm/dd/yyyy) |  |  |  |\n| Request Type\u003Cbr>☐ Initial\u003Cbr>☐ Concurrent |  |  | Service Request\u003Cbr>☐ Routine\u003Cbr>☐ Expedited/Urgent** (select expedited for ACT and IHBT) |  |  |  |\n| Member Name |  |  | Date ofBirth (mm/dd/yyyy) |  |  |  |\n| Member Phone Number |  |  | Member Medicaid ID\\# |  |  |  |\n| Provider Information |  |  |  |  |  |  |\n| Billing Provider/Agency Name |  |  | Billing Provider/Agency Service Location |  |  |  |\n| Provider/Agency Contact Name |  |  |  |  |  |  |\n| Provider NPI | Provider Tax ID Number |  | Phone Number |  | Fax Number |  |\n| Medicaid Provider Number |  |  | Provider Status\u003Cbr>☐ MCE Contracted ☐ MCE Non-contracted |  |  |  |\n| Service Requested |  |  |  |  |  |  |\n|  |  | Service Code Requested |  | Units/Visits Requested |  | Requested Start Date or Dates of Service |\n| Assertive Community Treatment* |  | ☐H0040 |  |  |  |  |\n| MRSS Stabilization Service (more than 6 weeks) |  | ☐S9482 |  |  |  |  |\n| Psychological/Neuropsychological Testing (> 20 hours per calendar year) |  | ☐96130 ☐96131 ☐96136 ☐96137\u003Cbr>☐96132 ☐96133 |  |  |  |  |\n| SBIRT Services |  | ☐G0396 ☐G0397 |  |  |  |  |\n| Psychiatric Diagnostic Evaluation |  | ☐90791 ☐90792 |  |  |  |  |\n| Alcohol or Drug Assessment |  | ☐H0001 |  |  |  |  |\n| Peer Support (more than four hours on same day) |  | ☐H0038 |  |  |  |  |\n| Partial Hospitalization (Medicare only) |  | ☐G0410 ☐G0411 |  |  |  |  |\n| Other Services/Out-of-network Providers |  |  |  |  |  |  |\n| OhioRISE Only Services |  |  |  |  |  |  |\n| Behavioral Health Respite* |  | ☐S5150 ☐S5151 |  |  |  |  |\n| Intensive Home-Based Treatment* |  | ☐H2033 ☐H2015 |  |  |  |  |\n| Primary Diagnosis (ICD-10)– including provisional diagnosis |  |  |  |  |  |  |\n\n*Services marked with an asterisk (*) may require additional assessment results to be provided (e.g. ANSA, CANS [including CIP-IHBT version],  \n\n| Instructions for Service Requests |\n| --- |\n| Requests for Substance Use Disorder (SUD) Residential Treatment (H2034 and H2036) and Partial Hospitalization (H0015TG) should be submitted using the ODM 10276 “Substance Use Disorder Services Prior Authorization Request” form.\u003Cbr>The following information should be submitted to the MCE with this form:\u003Cbr>• Include service start date and referral source along with reason for services\u003Cbr>• Attach clinical documentation (e.g. Assessment Summary, ISP with Diagnostic Summary, Clinical Summary) to provide justification that the member meets criteria for a service.\u003Cbr>• Provide primary/secondary diagnoses and psychosocial issues/barriers to treatment\u003Cbr>• Provide pertinent medical and BH history including suicidal ideation/homicidal ideation risk\u003Cbr>• Provide treatment plan with target dates and discharge plan\u003Cbr>• For continued stay requests please provide: any new problems identified, an update on the treatment plan including how lack of progress is being addressed in any areas, updated discharge plan, and updated information on psychosocial barriers. |\n\nAchenback)","cbCair7EdMlHu7zl","https://ap.wps.com/l/cbCair7EdMlHu7zl","pdf",118411,"English","# Managed Care Entity Contact Information\n## Member and request details\n## Provider and billing information\n## Service requested selections\n## Instructions for service requests","[{\"question\":\"What information does the Ohio Medicaid Authorization Form request from the managed care entity and member?\",\"answer\":\"It requests managed care entity contact selections, request type (initial or concurrent), service request type (routine or expedited/urgent), member name, date of birth, phone number, and Medicaid ID, plus date of request.\"},{\"question\":\"Which provider and billing fields are included in the form?\",\"answer\":\"The form includes billing provider/agency name and service location, provider contact name, provider NPI, tax ID, phone and fax numbers, Medicaid provider number, and provider status (MCE contracted or non-contracted).\"},{\"question\":\"What must be submitted for SUD residential treatment and partial hospitalization service requests?\",\"answer\":\"Requests for specific SUD services should use the ODM 10276 prior authorization form and include service start date and referral source with reason, attach clinical documentation for justification, provide primary/secondary diagnoses and psychosocial issues, include medical and behavioral health history with risk considerations, and include a treatment plan and discharge plan, with updates for continued stay requests.\"}]","Ohio Medicaid Authorization Form - Managed Care Entity Contact Information | PDF"]