03/01/2023

Summary of New ODM Initiatives Launched February 1

One month ago Ohio Department of Medicaid (ODM) launched the Next Generation managed care plans, new Electronic Data Interchange (EDI), and Fiscal Intermediary (FI). These initiatives provide an enhanced and personalized healthcare experience for ODM members with more transparency and visibility of care and services for providers. 

As a reminder . . .

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. Please work with your trading partners if you would like to request confirmation of a claim already submitted.

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. Claims submitted via trading partners are not viewable within the PNM module.

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. 

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.

Other Important Reminders:

Update on remittance advices for fee-for-service claims delivered via PNM 

Ohio Department of Medicaid is addressing an issue where fee-for-service remittance advices are unable to be viewed in the Provider Network Management (PNM) module. All fee-for-service remittance advices will be available in the PNM module by Tuesday, February 21, 2023. 

PNM affiliation steps are not complete and may impact provider billing

Through a series of PNM queries, Ohio Department of Medicaid (ODM) has identified several affiliation issues that impact billing organizations claims. It is imperative that providers fully execute all steps when affiliating a rendering provider to their group/organization/hospital to avoid claims payment issues. ODM has identified that providers tend to leave affiliations in one of two incomplete statuses (Affiliation Status):

• Pending Approval

• Confirmed

A provider affiliation can be initiated and completed by the group/organization/hospital, or it can be initiated through the rendering practitioner. If the affiliation is initiated through the rendering individual, it is not complete and remains in a “Pending Approval” status until the group/organization/hospital accepts and saves the affiliation. At that point it will appear as “Confirmed”. For the provider affiliation to be sent downstream and receive an “Active” status, there are two remaining critical steps:

1. Click at the top of the page, which saves all the updates. Once saved, the user will have a new button appear.  
2. Click . Users must click on this button to complete the process and submit the affiliations downstream. Affiliations are fully executed ONLY once this final step has been taken.   

Important: If these steps are not completed, the provider affiliation is not sent downstream, and providers will experience claims payment issues. 

For more information

The PNM ‘Learning’ Tab includes step-by-step instructions in three Quick Reference Guides (QRGs) for affiliation assistance.