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  • Provider Adjustment Request Form - Buckeye Community Health Plan

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Acknowledged as requests for adjustment only. Note: Requests must be submitted within 180 days of the original disposition of the claim. All fields in the box immediately below are required information. Date of Request: Provider Name: Provider Number: Claim.

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Buckeye Health is a Medicaid plan for adults and children in Ohio. Eligibility is determined by family size and income. Buckeye Member Services (1-866-246-4358 OR TDD/TTY: 1-800-750-0750) can answer questions about Buckeye Health Plan.

Your appeal must be requested within 60 calendar days of the decision you are appealing and the request must include: Your name. Address.

Submit the Adjustment within 180 days from the date of the EOP.

Appeal Form ing to state guidelines, you have 60 days from the date of service, adverse decision, or initial provider bill to request an appeal. Please complete this form to the best of your ability and return it by mail, email, fax, or by hand delivery.

To ask for a hearing, call or write your local agency or write to the Ohio Department of Job and Family Services, Bureau of State Hearings, PO Box 182825, Columbus, Ohio 43218-2825. If you receive a notice denying, reducing or stopping your assistance or services, you will receive a state hearing request form.

Complaints and Appeals Call the Member Services department at 1-866-246-4358 (TDD/TTY: 1-800-750-0750) Fill out the form in your member handbook. Call the Member Services department to request they mail you a form. Visit our website at .buckeyehealthplan.com.

The address to mail a provider appeal is: 4349 Easton Way, Suite 120, Columbus, OH 43219. Providers may file a provider appeal electronically using the Buckeye provider portal.

225.2573 ext: 6075525 or via e-mail at: EDIBA@centene.com Payor ID 68069 Visit .buckeyehealthplan.com Click Provider Home/Resources/ Electronic Transactions (EDI).

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232