This MITS BITS provides an update to and replaces the communication sent on June 16, 2022, regarding the use of practitioner modifiers on Aetna OhioRISE claims submitted by community behavioral health providers.
In preparation for the launch of OhioRISE on July 1, 2022, and in preparation for the Ohio Department of Medicaid’s (ODM’s) implementation of the “front door” for claims submission later this year, ODM and Aetna Better Health of Ohio have agreed to align OhioRISE practitioner modifier requirements for outpatient and professional claims with those used in ODM’s fee-for-service program.
In accordance with this set of changes, the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page, were updated today. Both documents now describe Aetna’s practitioner modifier requirements for outpatient and professional claims as aligning with those in ODM’s fee-for-service program.
With the implementation of this update in Aetna’s billing requirements, Aetna will NOT REQUIRE practitioner modifiers on the following types of claims, unless the rendering practitioner holds multiple licenses or credentials with differing scope of practice (see section below).
- Community mental health agency claims (provider type 84).
- Community substance use disorder treatment provider claims (provider type 95).
- OhioRISE care management entity (CME) claims.
- Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
- Outpatient hospital claims submitted for Enhanced Ambulatory Patient Groups (EAPG) reimbursement.
In alignment with ODM fee-for-service policy, Aetna will require practitioner modifiers on outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement. Aetna’s OPHBH practitioner modifier requirements will mirror ODM’s fee-for-service requirements.
Practitioners with multiple licenses or credentials
Aetna will require rendering practitioners holding multiple licenses or credentials with differing scopes of practice to use ODM’s requirements for enrollment and claims submission, including:
- Provider enrollment with a multi-license specialty.
- Rendering provider reporting their additional licensure/credentials on claims.
- Use of modifiers identified on ODM’s dual licensure grid, which can be found on https://bh.medicaid.ohio.gov/manuals.
Aetna will be reconfiguring its claims engine to incorporate the requirements outlined above. Until this reconfiguration is complete, Aetna will need to process some claims manually. Providers will not be required to resubmit or adjust claims at a later date if their claims are processed manually because of Aetna’s reconfiguration timeline.
As noted in a previous MITS BITS, other changes were made to the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity Manual on June 14, 2022, including some clarifying language and corrections made based on stakeholder feedback. Those changes are noted in the version logs at the beginning of each document.
The Medicaid Behavioral Health Provider Manual was also updated on 6/14/2022 to clarify that CANS assessments must be entered in Ohio’s CANS IT system only to establish and maintain OhioRISE eligibility.
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