Follow Us On:

First Name:
Last Name:
E-mail:	* All input fields are mandatory.

NEW: 2011

Rx Prior Authorization Form

Synagis Prior Authorization Form: NEW FORM

To assist in simplifying the prior authorization process for Synagis, the 7 Medicaid Care Coordination Plans have developed a Synagis Prior Authorization Form with criteria based on the 2009 American Academy of Pediatrics Red Book Guidelines.

MCP Pharmacy Reference Guide / Preferred Drug List (PDL)

Summer: 2010

Prenatal Risk Assessment

Early Periodic Screening and Diagnostic and Treatment (EPSDT)  brochure including diagnosis codes and a summer 2010 webinar schedule. 

EPDST Well Child Visit Checklist Documents:

• Newborn, 1 Week Visit
• Newborn, 4 Week Visit
• 2 Month Visit
• 4 Month Visit
• 6 Month Visit
• 9 Month Visit
• 1 Year/12 Month Visit
• 15 Month Visit
• 18 Month Visit
• 2 Year/24 Month Visit
• 30 Month Visit
• 3 Year Visit
• 4 Year Visit
• 5 Year Visit
• 6 - 10 Year Visit
• 11 - 14 Year Visit
• 15 - 20 Year Visit 

Standardized Medicaid Prior Authorization information:

• A grid comparing all 7 Medicaid plans' requirements.
• Prior authorization instruction sheet.
• Prior authorization standardized form that all plans use.

Medicaid FAQ:
Read provider-specific FAQs relative to Medicaid in Ohio.
> View PDF

Provider specific benefit explanations:
Learn about the benefits providers receive from Medicaid Care Coordination plans.
> Visit Site

Nursing Facility Stay Form:
Review instructions and fill out the review form for nursing facility stay.
> View PDF

Home Health Approval Form:
Our new Home Health Prior Authorization form.
> View PDF

*** For Provider Complaint Forms, please go to the Medicaid Care Coordination Plan's website by clicking a logo below.