How to Fill Out and Submit the Buckeye Provider Appeal Form

The Buckeye provider appeal form — officially the Claim Appeals, Reconsiderations and Disputes form — is the cover sheet you attach to a mailed or faxed challenge of a denied, underpaid, or incorrectly processed Buckeye Health Plan claim. To get it processed on the first try, complete every field on the current version of the form, attach the documentation that matches your dispute type, and submit within the deadline tied to the date of service. Buckeye (now operating under Wellcare branding as part of Centene) also accepts most disputes through its provider portal, which is the method the plan recommends because it generates a tracking record you can check later.¹

Pick the Right Type of Request First

Buckeye uses different labels depending on what you’re challenging and when the service occurred, and the label determines which form and which submission path you need.

For claims with a date of service on or after February 1, 2023, every post-service disagreement is a “dispute,” whether you’re contesting a coding denial, a payment amount, or a clinical determination. Disputes involving medical necessity or level-of-care review require an additional medical necessity review form along with clinical records. Disputes that don’t involve medical necessity — billing errors, incorrect denials, coordination-of-benefits issues — go through a simpler portal submission.¹

For claims with a date of service before February 1, 2023, Buckeye still distinguishes between “disputes” (non-clinical) and “appeals” (clinical). A clinical appeal for an older claim uses a different version of the medical necessity review form.¹

Pre-service appeals, where Buckeye denied a prior authorization before the service was performed, follow a separate process with different submission points: the provider portal, fax to 866-719-5404, or mail to Buckeye Health Plan, 4349 Easton Way, Suite 120, Columbus, OH 43219.²

Know Your Deadline Before You Start

Timing depends on when the service was performed. For claims with a date of service on or after February 1, 2023, you can file no later than 12 months from the date of service or 60 calendar days after the payment, denial, or partial denial, whichever date falls later. That “whichever is later” clause matters: if your denial came 10 months after the service date, you still get a full 60 days from that denial.¹

For claims with a date of service before February 1, 2023, the window is 365 days from the date of service or 60 days from the date of the Explanation of Payment, whichever is later.¹

The 60-day count runs from the date printed on the Explanation of Payment, not the day your billing department opens the envelope. Every calendar day counts, including weekends and holidays. Missing the window usually means the dispute will not be processed on the merits.

Fields You Have to Complete

Buckeye returns incomplete submissions without processing them, so every required field needs to be filled in. The current form asks for:³

Provider information: facility or provider name, Tax ID, and NPI.
Member information: member ID and whether you are a participating or non-participating provider.
Claim details: claim number, dates of service, and authorization number if the denial was authorization-related.
Request type: claim appeal, claim payment dispute, or claim reconsideration.
Plan type: Medicaid or Medicare, matching the member’s coverage.
Reason for the request: a written explanation of why you disagree with the original determination.
Contact person: name, direct phone number, and fax number for the person handling the appeal.
Signature and date.

Confirm that the Tax ID and NPI on the form match what Buckeye has on file for your practice. A mismatch between your submitted identifiers and your enrollment record can stall processing before a reviewer ever looks at the clinical merits.

What to Attach

The form is a cover sheet. What you attach to it decides whether the dispute succeeds or gets upheld. The form includes a checklist of attachment types; mark each one you’re including so the reviewer knows what to look for in the packet.³

For medical necessity disputes, include an appeal letter laying out the clinical rationale, and attach the relevant medical records: progress notes, lab results, imaging reports, anything that demonstrates why the service was appropriate for the patient’s condition. A bare letter without records gives the medical director nothing to overturn.

For payment disputes (wrong amount, coordination-of-benefits errors, duplicate denial), include itemized bills and the Explanation of Benefits from the primary insurer if the denial involved coordination of benefits. If the claim was denied for lack of authorization, attach proof that the authorization was obtained. The authorization number on the form alone may not be enough if Buckeye’s system doesn’t reflect it.

For every submission, include any additional correspondence, corrected claim documentation, or proof of timely filing that supports your case. Label every attachment clearly and reference it in the reason field so the reviewer can connect the documentation to your argument.

How to Submit

Buckeye accepts the form through three channels. The portal is the fastest and the one Buckeye recommends because it generates tracking data.¹

Provider Portal

Log in to the Buckeye provider portal from the provider home page. Select Medicaid and your TIN. For post-service disputes that don’t involve medical necessity, submit through the portal’s dispute workflow. For medical necessity disputes, upload the completed medical necessity review form with your supporting documentation.¹

Fax and Mail

If you submit by fax or mail, use the completed form as your cover sheet. The current submission points are:³

Fax: 1-833-957-0439
Mail: Wellcare by Allwell, PO Box 3060, Farmington, MO 63640-3822

Buckeye’s mailing address and fax number have changed from what older versions of the form listed. Submissions sent to outdated contact points may never reach the appeals department, so download the current form from the Buckeye website before each submission. If you fax, keep the transmission confirmation report as proof of timely filing.

You can also reach Buckeye Provider Services at 866-296-8731, Monday through Friday, 7:00 a.m. to 8:00 p.m., to check on the status of a previously submitted dispute or to initiate a verbal dispute.¹

What Happens After You Submit

Buckeye’s internal review team examines the form, the attached documentation, and the original claim file. For disputes involving medical necessity, a medical director reviews the clinical records. Once a resolution is reached, Buckeye reprocesses the claim, either upholding the original denial or adjusting the payment, within 30 days of the written notice of resolution.¹

Federal regulations cap the standard resolution timeframe for managed care appeals at 30 calendar days from the date the plan receives the appeal. Expedited appeals, reserved for situations where delay could seriously jeopardize the member’s health, must be resolved within 72 hours.⁴ Under Ohio’s administrative code, the plan must acknowledge receipt of a written appeal within three business days.⁵

The decision arrives by mail or through the portal’s secure message center. If the denial is overturned, a new Explanation of Payment reflecting the corrected amount follows. If the denial is upheld, the written notice should explain the reasoning and the options for further review.

If Buckeye Upholds the Denial

Two escalation paths exist once Buckeye’s internal review is complete. Providers who have exhausted the internal process can file a complaint with the Ohio Department of Medicaid using the Managed Care Provider Complaint Form; the Department will not process a complaint until the internal appeal or dispute has been run first.⁶ For denials based on medical necessity, Ohio also offers an external medical review by an independent entity, with the request due within 30 calendar days of written notice that Buckeye’s internal process is complete.

Common Reasons Submissions Get Kicked Back

Several patterns account for most procedural denials:

Incomplete form. Missing fields, including the contact person’s direct phone and fax, trigger a return without review.
No supporting documentation. Without medical records, itemized bills, or authorization proof, the reviewer has nothing to evaluate beyond the data that already produced the denial.
Wrong submission path. Sending a medical necessity dispute through the standard portal workflow without the medical necessity review form, or mailing to an outdated address, delays or derails the review.
Missed deadline. Filing after the 60-day window from the Explanation of Payment closes, even by one day, typically results in a procedural denial regardless of the claim’s merits.
Identifier mismatch. An NPI or Tax ID on the form that doesn’t match Buckeye’s enrollment records prevents the system from linking the dispute to your provider profile.

1
Buckeye Health Plan. Post Service Provider Disputes-Appeals
2
Buckeye Health Plan. Pre-Service Provider Appeals
3
Buckeye Health Plan. Claim Appeals, Reconsiderations and Disputes Form
4
eCFR. 42 CFR 438.408 – Resolution and Notification
5
Ohio Legislative Service Commission. Ohio Administrative Code 5160-26-08.4 – Managed Care Appeal and Grievance System
6
Ohio Department of Medicaid. Ohio Medicaid Managed Care Provider Complaint Form