OHIO NEXT GENERATION MEDICAID 2023 IMPLEMENTATION

Are you ready?

In an effort to better understand agency readiness for December 1st, 2022, including MITS integration into the PNM, Fiscal Administrator (One Front Door), and MCO procurement, we have put together a short survey.

We would like this to be completed by the staff members familiar with and responsible for ensuring system setup and billing guidelines. Please forward this to the appropriate team member at your agency.

Please take a minute and select the link below to complete the survey. Your answers will help us understand whether or not Behavioral Health agencies are ready for these changes.

Next Generation Medicaid Timeline & Overview

The Ohio Department of Medicaid is introducing its Next Generation managed care plans to focus on the individual, honor members’ choices, and provide continuity in the provision of members’ care. These changes do not apply to MyCare.

The Next Generation of Ohio Medicaid program will be implemented in stages to avoid unnecessary disruption and confusion for members and to reduce burdens on our service providers. The Next Generation program will be implemented in the following stages:

Stage 1: On July 1, 2022, OhioRISE started providing specialized services, which will help children and youth with behavioral health needs and help coordinate care for those who receive care across multiple systems.

Stage 2: On October 1, 2022, Centralized Provider Credentialing will begin, which will reduce the administrative burden on providers. Also, the Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members.

Stage 3: On February 1, 2023, the implementation of the Next Generation managed care plans will occur. Members will experience benefits that help address their individual healthcare needs, such as increased access to care coordination and care management support. Also, in stage three, ODM will implement additional improvements to streamline the process of claims and prior authorization submission for providers.

Important Updates on Next Generation Launch 

From ODM communication on 11/17/2022

Over the past year, Ohio Department of Medicaid (ODM) has prepared for and successfully launched many components of the Next Generation Ohio Medicaid program. Our implementation has consistently followed our key Next Generation commitment – to focus on the individual. To meet these commitments, on July 1, ODM implemented OhioRISE (Resilience through Integrated Systems and Excellence) and on October 1, we implemented the Single Pharmacy Benefit Manager (SPBM). The feedback has been clear about the significant benefits members have experienced because of these new program changes.

Our focus has been and continues to be on implementing new components and improvements as they are fully ready to support achieving our mission. ODM remains committed to listening to members and we have taken a hands-on approach to resolving implementation issues that have been experienced.

What is changing?

Based on the feedback we have received and our commitment to carefully transitioning, we will not implement the new Next Generation managed care plans launch on December 1. ODM will launch the Next Generation managed care plans and program requirements on February 1, 2023, including exciting improvements that will support members in accessing the healthcare services and supports they need.

What does this mean for members?

There will be no disruption in services for members. The timeline during which a member’s Next Generation managed care plan will be effective varies based on which plan they selected.
Managed care members that have not made an active plan selection will continue receiving healthcare coverage through their current managed care plan.

• Paramount Advantage members will continue receiving healthcare coverage through Paramount Advantage until February 1. At that time Anthem will be their Next Generation managed care plan, unless they selected a different plan.
• Managed care members that selected a new Next Generation managed care plan will begin receiving services from that plan February 1.
• Managed care members that selected a different continuing plan, such as CareSource Ohio, Inc., Buckeye Health Plan, Molina Healthcare of Ohio, Inc., or United Healthcare Community Plan of Ohio, Inc., from their current plan will begin receiving services from that plan on December 1.
• Individuals who are newly eligible for managed care, those who are currently in Medicaid fee-for-service but not enrolled with a managed care plan, and those with a gap in eligibility of 91+ days will receive care paid for through Medicaid fee-for-service until February 1, 2023 when they are transitioned to an Ohio Medicaid Next Generation plan.

Communicating with ODM

The Next Generation mailbox remains open as a way for individuals, providers, and advocates to communicate to ODM about the Next Generation of Ohio’s managed care program.

• Questions regarding OhioRISE can be directed to OhioRISE@medicaid.ohio.gov
• Questions regarding the Single Pharmacy Benefit Manager can be directed to MedicaidSPBM@medicaid.ohio.gov
• Questions regarding the Fiscal Intermediary can be directed to ODMFiscalIntermediary@medicaid.ohio.gov
• Questions regarding the PNM Module can be directed to PNMCommunications@medicaid.ohio.gov or PNMSupport@medicaid.ohio.gov
• Questions regarding Centralized Credentialing can be directed to Credentialing@medicaid.ohio.gov

Information provided by: Next Generation of Ohio Medicaid Managed Care | Ohio Medicaid Managed Care

Provider Network Management (PNM)

What is PNM?

The Ohio Department of Medicaid (ODM) is in the process of modernizing its management information systems. This modernization roadmap, developed in accordance with the Centers for Medicare and Medicaid Services (CMS) guidance, includes a transition to a modular system called the Ohio Medicaid Enterprise System (OMES) that will support ODM in meeting several modernization goals.

As a part of this roadmap, new, updated functionality is being built into OMES rather than MITS. The PNM is a new modular component of OMES, which has replaced the current MITS provider enrollment subsystem and provider portal.

What benefits are included with PNM?

There are several new features and enhancements in the PNM module that are designed to streamline processes and reduce administrative burdens for providers. The module allows providers to:

1. View specialties and effective dates.
2. Review and accept submitted provider change or update requests.
   1. There is no need for emails or letters – this includes change of operator notices, name changes, adding specialties, etc.
3. Access a comprehensive provider directory at the state level.
4. Opt in or out of text message notifications.
5. View all long-term care agreements online.
   1. No more paper agreements – those available online do not require mailing back and forth for signatures.

Centralized Credentialing

What is Centralized Credentialing and what benefits does it provide?

ODM implemented a single, centralized provider credentialing process at the state level with the go-live of the PNM portal. There are many expected benefits of this centralized approach, including:

• Providers subject to credentialing will only undergo one credentialing and recredentialing process at the state level vs. a separate additional process for each Ohio Medicaid managed care organization (MCO).
• A credentialing verification organization (CVO) – Maximus, Inc. – will maintain National Committee for Quality Assurance (NCQA) accreditation requirements for Ohio’s MCOs and serve as ODM’s single point of contact for providers as they undergo credentialing and recredentialing reviews.
• By establishing delegate agreements with hospital systems and a delegate review process, ODM can deem credentialing work already completed by these providers and reduce or eliminate the need for individual providers such as physicians, nurse practitioners, etc., to engage in multiple credentialing processes.
  Centralized Credentialing Infographic

Information provided by: About Provider Network Management and Centralized Credentialing | Ohio Medicaid Managed Care

Fiscal Intermediary

The Fiscal Intermediary (FI) is a part of a larger effort to modernize ODM’s management information systems. This modernization roadmap, developed with guidance from the Centers for Medicare and Medicaid Services (CMS), includes a transition to a modular system called the Ohio Medicaid Enterprise System (OMES).

As a part of this roadmap, the FI was integrated into OMES to support updated and new functionality. Beginning December 1, the FI will replace both the Medicaid Information Technology System (MITS) and other financial subsystems. The FI will facilitate the processing of claims and prior authorizations by providers and trading partners, submitted through either the Provider Network Management (PNM) module or Electronic Data Interchange (EDI).

In coordination with EDI, FI will assist in transitioning claims and authorizations to Ohio Medicaid’s future managed care entities (MCE) and receive updates from those organizations. By doing so, providers can receive appropriate updates, making the process more transparent and efficient.

Functions of the Fiscal Intermediary

• Adjudicate all fee-for-service (FFS) claims from the PNM and EDI.
• Facilitate the processing of FFS prior authorization requests.
• Assist in routing managed care claims and prior authorization requests to MCEs.*
• Validate encounters from MCEs that result from their claims processing and facilitate data exchange with MCEs.
• Provide payment to providers for FFS recipients through the PNM and EDI.**
• Provide other payments directed by the state, such as comprehensive primary care and other lump sum payments.
• Manage financial data for Medicaid and related programs operated by OMES.

*MyCare claims and prior authorizations will not be coming through OMES. Providers will continue to submit those claims and prior authorizations to the MyCare managed care plans.

**The FI will not be replacing provider payments made directly by MCEs.

Next Generation of Ohio Medicaid Program Provider Webinar

Ohio Department of Medicaid (ODM) hosted the Next Generation of Ohio Medicaid Program Provider Webinar in July to share information about exciting changes Ohio Medicaid providers can expect. The webinar included an overview of the transition to the OMES modules – including the Single Pharmacy Benefit Manager (SPBM), Provider Network Management (PNM), and the Fiscal Intermediary (FI) – along with information on planned, module-specific trainings.

Please find a recording of the presentation and slides here: Providers | Ohio Medicaid Managed Care.

Information provided by: Fiscal Intermediary | Ohio Medicaid Managed Care

Trading Partner Updates & Resources

• This is the Q&A document from the EDI OMES Trading Partner Training webinar held on October 28, 2022: 102822 EDI OMES Trading Partner Training Webinar – Q&As

Resources

PNM Handouts

• Updates-Revalidation (BH Organization)
• QRG – Adding a Group Affiliation
• QRG – Adding a Hospital Affiliation
• QRG – Agent Assignment & Actions
• QRG – Creating OH ID for IOP PNM Login
• QRG – Enabling SMS Recovery for OH ID
• QRG – Finding Your OH ID
• QRG – DODD New Provider Application
• QRG – EVV Training
• QRG – General Application
• QRG – Identifying your role within PNM
• QRG – New Provider Application
• QRG – ODA New Provider Application
• QRG – PNM Initial Login
• QRG – Provider Correspondence
• QRG – Provider Directory
• QRG – Provider Homepage
• QRG – Provider Public Search
• QRG – Revalidation
• QRG – Select and Transfer Providers
• QRG – Self-Service Functions (Redirect to MITS)
• QRG – Updating a Provider File
• QRG – Upload Documents
• Behavioral Health Provider Data Entry (Individual)
• Behavioral Health Provider Data Entry (Organization)
• CHOP Entry (Provider)
• Comprehensive Primary Care
• Credentialing Guide and Requirements
• Delegated Credentialing (Delegates)
• Facility Provider Data Entry
• Ohio Department of Aging Provider
• OhioRISE
• Provider Enrollment (Group/Organization)
• Provider Enrollment (Individual)
• Accessing MITS Redirect as Admin or Agent

• How To Affiliate a Provider in PNM
• How to Assign BHBS as Your Agency’s PNM Administrator
• How to Register for OHID PNM Agent Account

Additional Resources

• Centralized Credentialing FAQ – September 2022 Update
• 12/14/2022 Screenshots of PNM Refresher by Maximus
• Spreadsheet to Mass Add Providers to PNM Administrator Account This will be emailed to PNMSupport@Medicaid.Ohio.Gov
• PNM Training Modules Use enrollment key ‘bhorgprovider’
• Clearing Cache and Cookies in Chrome or Edge You may need to use this if you are having issues accessing MITS through the PNM

Provider Master Files

• CBHC Practitioner Enrollment File_as of 1.7.23 – Type 84 & Type 95 Combined
• CBHC Practitioner Enrollment File_as of 12.31.22 – Type 84 & Type 95 Combined
• CBHC Practitioner Enrollment File_as of 12.10.22 – Type 84 & Type 95 Combined
• CBHC Practitioner Enrollment File_as of 12.3.22 – Type 84 & Type 95 Combined
• CBHC Practitioner Enrollment File_as of 11.26.22- Type 84 & Type 95 Combined