Notification of substance use disorder residential admissions

The Ohio Department of Medicaid (ODM) Substance Use Disorder Residential Treatment Notification of Admission Form is a tool used by providers of substance use disorder residential treatment services to notify managed care entities (MCEs) of Medicaid member admissions. The form should be submitted to the MCE within 48 hours of patient admission, and the MCE will then complete Section III and return the form to the provider within 24 hours.

For Anthem members enrolled in Medicaid, the ODM Substance Use Disorder Residential Treatment Notification of Admission Form should be emailed to ohbhcasemanagement@anthem.com.

Please do not fax these forms to the prior authorization fax numbers as this will delay response time.

 You can find the Substance Use Disorder Residential Treatment Notification of Admission Form with the contact information for submission at medicaid.ohio.gov/static/Resources/Publications/Forms/ODM10294Fillx.pdf.