02/13/2023

Claim Submission and Adjudication Reminders for Ohio Medicaid Next Generation

Important Message from the Ohio Department of Medicaid

 

With the launch of the new Electronic Data Interchange (EDI) along with the Fiscal Intermediary (FI) as part of the Next Generation of Ohio Medicaid program on February 1, the EDI became the new exchange point for trading partners on all claims-related activities, providing transparency and visibility regarding care and services. The FI, in conjunction, now assists in routing managed care claims submitted to the EDI and adjudicates and pays fee-for-service (FFS) claims submitted to the EDI.

We understand this transition has adjusted how you submit and access claims. Please refer to the guidance below for direction and reminders on the claim submission process.

Where do you submit claims?

For providers who utilize direct data entry (DDE):

• FFS claims submitted using DDE continue to be submitted from a Medicaid Information Technology System (MITS) portal page accessed via a link in the Provider Network Management (PNM) module. FFS claims submitted through the PNM module continue to be paid by OAKS, the State of Ohio’s accounting system.
• Managed care claims submitted using DDE should be processed through the applicable managed care entity (MCE) portal.

For providers who utilize a trading partner:

• All managed care and FFS claims submitted by trading partners are submitted through the new EDI. Providers with a trading partner should confirm their trading partner has completed all required connectivity activities with Deloitte, the new EDI vendor.

Where do you submit claim attachments?

• All managed care attachments are handled by the applicable MCE. Providers should work with each MCE to submit attachments following the process outlined by that MCE.
• FFS claim attachments are submitted from a MITS portal page accessed via a link in the PNM module. Trading partners do not submit attachments on behalf of providers.

Where do you edit claims?

Edits to claims, including adjustments and voids, are submitted utilizing the same method (MCE portal, MITS page accessed via the PNM module, or through a trading partner utilizing the new EDI) as the original claim submission.

Where do you go for more information on claims?

For claims submitted but not yet paid:

• If a trading partner submitted the claim through the new EDI and the claim was passed to the MCE, including claims sent from Ohio Department of Medicaid (ODM) to the MCE for adjudication, the provider should visit the applicable MCE’s portal.
• FFS claims submitted but not yet paid are not visible to providers. These claims will not be visible in the PNM module until a future system release.

For paid claims:

• All payers' .pdf remittance advices (RA) are available to providers on the PNM portal. This includes MITS, FI, and MCO RAs.
• If a provider is enrolled with ODM to receive an 835, that enrollment applies to both FFS and MCO activity. 835s from all payers are delivered by the trading partner.

Additional information on claim submission for providers who utilize trading partners 

With the launch of the new EDI, changes in the claim submission process are required for trading partners to exchange transactions in the new EDI. Providers should work with their trading partners to determine the changes that may be needed to their systems and staff training. A few important changes for providers who utilize trading partners to note are as follows:

• 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.
• Provider claims submitted to trading partners must include the Medicaid member ID (MMIS). The Medicaid ID should be obtained with each visit. Member eligibility can be verified using the ID through the PNM module, which redirects to MITS.
• Each managed care claim must include the internal managed care payer ID and a receiver ID. FFS claims also require a payer and receiver ID but they remain the same. If you submit your own claims through the EDI, please refer to the ODM Companion Guides for the updated receiver and payer IDs list.

Do you have questions? 

Information is available on the submitting claims and prior authorizations page on the Next Generation website. For additional help contact the Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. Representatives are available during special hours February 1-24:

• 7 a.m.-7 p.m. Monday-Friday, except Monday, February 20, hours are 8 a.m.-5 p.m.
• 8 a.m.-5 p.m. Saturdays and Sundays.

After February 24, regular hours of 8 a.m.-4:30 p.m. will resume Monday-Friday.