Upcoming: daily provider data reconciliation to the Provider Network Management (PNM) and Provider Master File (PMF) system

Effective October 21, 2023, the Ohio Department of Medicaid has mandated the following to all Managed Care Organizations.

 

With the PNM system generated PMF as the Ohio Department of Medicaid’s (ODM) system of record, MCEs must direct ALL providers to update their ODM record in the PNM system when discrepancies are identified between the MCE’s data and the PNM PMF. Ohio Administrative Code rule 5160-1-17.2(F) requires all providers with a signed Medicaid provider agreement to “inform ODM within thirty days of any changes including, but not limited to changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or re-placements in group membership and hospital-based physician affiliations; and address, including all locations where servicers are rendered.” MCEs must not accept changes from providers into their own systems that are inconsistent with PNM system data shared through the PNM PMF for their Medicaid line of business.

 

To ensure the prompt and timely payment of claims for services rendered to Medicaid managed care members, the MCE must integrate and use PNM system data (PMF and all supplemental files generated by ODM systems) for claims adjudication and payment.

 

We will share more information as we receive it from the Ohio Department of Medicaid.

Do not send paper claims   

 

 

 

 

 

New form required when requesting an Administrator change across organizations
Ohio Department of Medicaid (ODM) developed a new form, ODM10304, that must accompany requests to change Provider Network Management (PNM) Administrators from one billing organization provider to another. As a security measure, you must submit a formal request to transfer Administrator ownership of a Medicaid ID within the PNM module. More details are available on ODMs website. 

 

Claim submission and adjudication FAQ is now available

ODM updated the Claims and Prior Authorization Submission Frequently Asked Questions (FAQ) to make it easier for you to find the information you need. It covers fee-for-service, managed care, and OhioRISE billing procedures, adjudication processes, and other answers to common provider questions. Review this document on the submitting claims and prior authorizations page on the Next Generation website and share it within your practice or organization. 
If you have questions, providers can contact the ODM Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday - Friday.

 

Updated HEDIS Guidelines for the Care Gap Closure program  

Click here to view the HEDIS 2023 Documentation and Coding Guidelines.

 

Ohio Department of Medicaid fraud warning

Criminals are targeting Medicaid recipients for sensitive, personal, and financial information. If your patient gets a call, text, or email about Medicaid benefits asking for a Social Security number, payment, bank, debit, or credit card information, advise your patient to not respond. They’re not from the State of Ohio or any agency. Instead, it should be reported to the Ohio Attorney General at 800-282-0515 or click here. 

Provider Claims and Billing Manual - Box 33, no PO Box allowed 

33 Billing Provider Info & Ph. # Required – Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable R 2010AA NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04

See page 17 of Provider Claims and Billing Manual.

 

Important requirements for Hospice Billing of (HCPC T2046) and Ventilator/Ventilator Weaning Services

If the above conditions are not met, the claim may be denied and require submission of a corrected claim. 

 

The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). If you have submitted a paper claim, you will be advised that your claim has not been processed and what your next steps should be. You can get started on our website with claims how-tos, quick guides, links and contact info.

 

Medicaid Annual Eligibility Redetermination Reviews

Information for providers regarding Annual Eligibility Redetermination Reviews is on our website. This federally required process is in place to ensure those enrolled in Medicaid programs continue to meet established eligibility criteria. AmeriHealth Caritas Ohio will collaborate with Ohio Department of Medicaid and our provider network to minimize the burden on our members and promote continuity of health coverage.

 

Billing guidelines

Clarifying language is being added to the behavioral health section of our billing guidelines: For services billed under the provider’s primary license, optional modifiers are not to be used.

 

Access AmeriHealth Caritas Ohio's provider resources

Step 1: Visit our provider webpage
Step 2: Sign up for NaviNet
Step 3: Attend a Provider Orientation Meeting
Step 4: Submit claims through Electronic Data Interchange (EDI)

We would love to hear from you!

Your voice matters and we want to hear your thoughts regarding participation in AmeriHealth Caritas Ohio's Population Health and Quality initiatives. Click here to take the one-minute survey.