Forms, Billing and Reference Guides

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Frequently Requested Provider Forms and Guides

Community Plan of Ohio Prior Authorization Supplemental Information Form
Ohio Nursing Facility Request Form
Ohio Primary Care Physician PCP Change Form
Pregnancy Risk Assessment Form (PRAF)
Synagis Enrollment Form
UnitedHealthcare Community Plan of Ohio - Interactive Quick Reference Guide
UnitedHealthcare Community Plan of Ohio Prior Authorization Resources
UnitedHealthcare Dual Complete Ohio Quick Reference Guide

ICD-10 Tips

The Ohio Department of Medicaid (ODM) ICD-10 team will post monthly ICD-10 TIPS which will offer clarification and guidance to ODM providers and ODM staff on the transition to the ICD-10 codes. The following links will take you to ODM resources concerning the ICD-10 transition.

Ohio Department of Medicaid ICD-10 Website

Submit a Pre-Service Appeal and or Grievance for a Medicaid Member

Medicaid Pre-Service Appeal or Grievance