Behavioral Health Billing Solutions
2/1/23 Next Generation Provider Webinar
ODM will be hosting a 1-hour webinar to share information on the changes Ohio Medicaid providers can expect in the next implementation scheduled for 2/1/23, including an overview of the transition to the Next Generation managed care plans, Electronic Data Interchange, and Fiscal Intermediary. Additionally, they will discuss key changes and where resources are available to assist providers in the transition.
Next Generation February 1 Launch Provider Webinar
Thursday, January 19, 2023
3 – 4 p.m. ET
EDI Module 8 Things to Know – Updated
ODM made updates to the previously communicated information on EDI changes. Regarding #5, we confirmed with ODM that providers must submit claims with a date of service on or after 2/1/23 to the new EDI module. However, it is permissible to send claims with a date of service prior to 2/1/23 to EDI module if the claims file structure meets all the new requirements for the EDI, which includes the new payer IDs, MMIS, and receiver IDs. More details are available in section 7 of the companion guides. Providers also have the option of submitting claims with a date of service prior to 2/1/23 to the MCO through their current process. ODM made this change to allow greater flexibility for providers when billing claims prior to 2/1/23.
Additionally, ODM shared detailed information with Ohio Council members on the required EDI changes. The slides from that presentation are available here.
On February 1, 2023, Ohio Department of Medicaid (ODM) will implement the new Electronic Data Interchange (EDI) module as part of the Next Generation program. Please take a moment and read through this email for the top eight things you need to know about the new EDI.
#1: The new EDI, supported by the vendor Deloitte, is replacing the current EDI.
On February 1, the new EDI will be the exchange point for trading partners on all claims-related activities including claim status and eligibility. All trading partner claims must be submitted directly to the EDI, regardless of whether the member is receiving benefits through Medicaid fee-for-service (FFS) or one of the Next Generation managed care plans. Please note that MyCare is not included in the Next Generation program and will continue to use current processes.
Providers who submit managed care claims through direct data entry (DDE) will do so via the appropriate managed care portal. All managed care prior authorizations will continue to be submitted to the respective managed care portals or through their respective processes. Additionally, FFS direct data entered claims and prior authorizations will continue to be submitted through the Provider Network Management (PNM) module via a link to Medicaid Information Technology System (MITS).
#2: There is a change in policy about rendering providers on claims.
For EDI‐related claims submissions, ODM now requires one rendering provider per claim at the header level, rather than the detail level, for professional claims for both FFS and managed care recipients. Different rendering providers at the detail level are no longer acceptable. Exceptions for FFS Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) providers are detailed in the Medicaid Advisory Letter 622.
#3: Provider claims submitted to trading partners must use the ODM-assigned Medicaid member ID (MMIS).
The Medicaid ID should be obtained with each visit. The Medicaid ID must be used on all EDI claim submissions. Member eligibility can be verified using the PNM portal, which redirects to MITS, or using the 270 /271 eligibility transaction in EDI.
#4: There will be system downtime leading up to February 1.
As we transition to the new EDI, there will be system downtime for processing of trading partner claims. They are as follows:
January 25-31: There will be an FFS (837 P/I/D) claims transition period.
January 30-31: There will be a member and claim inquiry blackout.
During this time ODM will not accept claims submitted via trading partners. Please work with your trading partner to discuss any changes or impacts to your submissions.
#5: *New Information* Pay attention to claims date of service when submitting for adjudication.
Claims with dates of service on or after February 1 must be submitted through the new EDI vendor, Deloitte. Claims with dates of service prior to February 1 should be submitted via the current processes.
#6: Check that your trading partner is authorized to work with ODM.
All clearinghouses or trading partners who are already authorized to submit claims to ODM will continue to have access to submit claims on behalf of providers. Please contact your trading partner to ensure they are ready to transition.
#7: Each managed care claim must include the internal managed care payer ID and a receiver ID.
All managed care claims submitted through the new EDI must include the internal managed care payer ID and a receiver ID. Please see the ODM Companion Guides for a full list of the updated receiver and payer IDs. Please note the payer and receiver IDs for FFS claims have not changed.
#8: Providers must submit attachments in the original method of claim submission.
Claim attachments must be submitted via the same method as the claim submission. For example, for a claim submitted via DDE, an attachment must also be done using DDE. For EDI transactions, please work with your trading partner on how to upload attachments. This is similar to the adjustment policy we detailed in the December 12 edition of the ODM Press.
PNM Updates and Fixes
ODM continues to implement fixes for identified issues in the PNM.
A fix was deployed resolving defects in the provider affiliation process. Providers are now able to affiliate and edit affiliations to their organization
Disenrollments will be processed within 2 business days
On 1/10/23 a fix will be deployed related to errors preventing the submission of a new provider application
There is a known data misalignment issue between provider data in the PNM and MITS which causes data to not synch between these systems. This impacts both the Provider Masterfile and CBHC files. This issue has been escalated and is being worked on for resolution.
ODM has committed additional resources to address the application backlog. We are striving to get application review time within a 30-day window.
ODM is finalizing an updated PNM Quick Reference Guide with step-by-step instructions for affiliations from the Group/Organization perspective. This includes a reminder to save the affiliation and click the “submit for review” button to send the affiliation downstream to other OMES modules.
Providers that need direct assistance with affiliations and assignment of Medicaid IDs to a PNM administrator or any other issues related to functionality of the PNM, please send an e-mail to: PNMCommunications@medicaid.ohio.gov.
Keep in mind, Behavioral Health Billing Solutions is here to make changes such as this easier.