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New “Next Generation” Medicaid ID Cards are being distributed to all managed care members beginning in August 2022
When will the Next Generation managed care identification card become effective?
Beginning October 1, 2022, Gainwell Technologies will become the Single Pharmacy Benefit Manager (SPBM) for all Ohio managed care members. As part of this transition, Medicaid managed care members will receive a new Next Generation (NextGen) identification card. NextGen ID cards will be mailed to members beginning August 15 and become effective for the SPBM on October 1. All pharmacy services provided before October 1 should be billed to the member’s existing managed care organization (MCO) pharmacy benefit. Reversals for claims originally billed before October 1, should be also sent to the original payer (the existing MCO pharmacy benefit).
What does the Next Generation managed care identification card look like?
Note: All Medicaid Managed Care members are receiving new ID cards with updated pharmacy information. Gainwell SPBM billing information is located on the front of the card, in the lower right corner.
What to do if presented with a Next Generation identification card before October 1?
Verify coverage in the Medicaid Information Technology System (MITS) and bill pharmacy services to the member’s assigned payer – fee for service (FFS) or managed care – using the information below.
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Use either the Fee-for-Service or Managed Care Plan billing information, as applicable. The OhioRISE Plan does not include a pharmacy benefit (pharmacy benefits are provided through the FFS Pharmacy Benefit Administrator (Change Healthcare) or the managed care plan PBM.
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Molina Healthcare of Ohio, Inc.
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RX0712, RX0714, RX0718, RX0759, RX0761, RX0854
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United Healthcare Community Plan of Ohio, Inc.
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How should pharmacies bill if a Medicaid managed care member does not have a Next Generation ID Card on or after October 1?
Beginning on October 1, all pharmacy claims for managed care members must be submitted to Gainwell Technologies, Ohio Medicaid’s Single Pharmacy Benefit Manager. Claims for fee-for-service members will continue to be submitted to the fee-for-service pharmacy benefit administrator Change Healthcare. While all necessary information is located on the NextGen ID Card, there may be instances where a member does not present the card.
If the member does not have the card, the pharmacy will need the following information to bill Gainwell:
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Gainwell RxBIN: 024251.
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Gainwell RxPCN: OHRXPROD (note: Gainwell does not require a group number).
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Ohio 12-digit Medicaid Member ID (formerly called the MMIS ID). Gainwell will NOT accept a secondary “Member ID” assigned by the managed care plans.
To obtain the Medicaid Member ID, you may check any of the following:
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The member’s existing Medicaid ID Card. The “MMIS ID” will be the “Medicaid Member ID” needed.
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The member’s digital ID card, accessible by the member on a mobile device (from the managed care plan website or mobile app).
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The Gainwell SPBM Pharmacy Portal, located at https://spbm.medicaid.ohio.gov. Pharmacies can obtain the member ID by logging into the secure area and searching for a member using any field. Results will show the member ID.
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Pharmacies that subscribe to SureScripts can query against Gainwell’s master patient index (this is not an E1 transaction).
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If a member does not have a Medicaid identification card, a pharmacy can verify coverage in MITS with the member’s demographic information and bill services to the appropriate payer.
If the above steps are not successful, you may contact the Gainwell SPBM help desk 24/7/365 at: 1-833-491-0344.
The following information can be used to bill a prescription in the absence of a Next Generation ID card after verifying member eligibility:
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Gainwell RxBIN: 024251.
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Gainwell RxPCN: OHRXPROD.
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Group Number is not needed.
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SPBM ID Number will be the member’s 12-digit Medicaid Management Information System (MMIS) ID.
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