Where do I submit claims? 

If you utilize direct data entry (DDE): 

• Submit fee-for-service (FFS) claims using DDE through the Provider Network Management (PNM) module, which redirects to the Medicaid Information Technology System (MITS). The Ohio Administrative Knowledge System (OAKS), the State of Ohio's accounting system, pays FFS claims submitted through the PNM module.
• Submit managed care claims through the applicable managed care entity (MCE) portal.

If you utilize a trading partner: 

• Trading partners submit all managed care, and FFS claims through the Electronic Data Interchange (EDI). Gainwell Technologies, the Fiscal Intermediary (FI) vendor, processes and pays FFS claims submitted through the EDI on behalf of ODM.

Where do I submit claim attachments? 

• All managed care attachments are handled by the applicable MCE. You should work with each MCE to submit attachments following the process outlined by that MCE. 
• You should submit FFS claim attachments through the PNM module. Trading partners do not submit attachments on your behalf. 

Where do I edit claims? 

• You should submit claim edits, including adjustments and voids, using the same method as the original claim submission. For example, if you submitted via an MCE portal, edits would be made in that MCE portal.  

Where do I go for more information on claims? 

For portal submitted claims: 

• You should use the same method (MCE portal or the PNM portal) as the original claim submission to obtain relevant claim information. 
• All payers' .pdf remittance advices (RA) are available to you in the PNM portal. This includes MITS, FI, and managed care organization (MCO) RAs.  
• If you are enrolled with ODM to receive an 835, that enrollment applies to both FFS and MCO activity. The trading partner delivers 835s from all payers. 

For EDI submitted claims: 

• If an MCE is adjudicating the claim, you should visit the applicable MCE's portal. 
• You cannot see EDI submitted FFS claims in the PNM portal, regardless of their status. This is working as designed. 
• All payers' .pdf RAs are available to you in the PNM portal. This includes claims submitted to EDI, PNM, and directly to MCOs. 
• If you are enrolled with ODM to receive an 835, that enrollment applies to both FFS and MCO activity. The trading partner delivers 835s from all payers. 
• Authorized trading partners can submit the 276 Claim Status transaction for more detailed information upon the receipt of the 277 Claim Acknowledgment (277CA). 

Additional reminders on claim submission if you utilize a trading partner: 

• For EDI‐related claims submissions, ODM 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 not acceptable. Exceptions for FFS Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) providers are detailed in the Medicaid Advisory Letter 622. 
• Claims submitted to trading partners must include the Medicaid member ID (MMIS). The MMIS should be obtained with each visit. Member eligibility can be verified using the MMIS 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? 

Additional information is available on the submitting claims and prior authorizations page on the Next Generation website. For additional help, 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 through Friday.