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As part of Ohio Department of Medicaid's (ODM) comprehensive effort to modernize management information systems, providers have experienced changes in how they submit and access claims. We know this is a big change and we appreciate your partnership. ODM would like to give providers some important reminders and clarification on two common questions.
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Where do I submit a crossover claim?
If Medicare has paid their portion of a claim but you do not receive ODM payment in the following ninety days, you must directly submit a corresponding crossover claim to ODM. You have the option to submit the crossover claim through the Provider Network Management (PNM) module via a link to Medicaid Information Technology System (MITS) or through a trading partner to the Electronic Data Interchange (EDI).
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Where do I edit fee-for-service, managed care, or crossover claims?
Submit claim edits, including adjustments and voids, using the same method as the original claim submission. For example, if you submit claims through a trading partner via the EDI you should only edit claims via the EDI. If you submit claims through the PNM module via a link to MITS, you should only edit the claim in the PNM.
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All providers offering personal care aide services to individuals on Medicaid Ohio Home Care and MyCare Ohio waivers must have a current first aid certification before providing services. The rule applies to agency and non-agency personal care aides (i.e., independent providers) as stated in Ohio Administrative Code 5160-46-04.
Keep your first aid certification current and available for audit or review purposes. Ohio Department of Medicaid (ODM) may request your first aid certification at any time. If you are audited or have a compliance review and do not have a record of your first aid certification, or other program requirements described in Chapter 5160 of the Ohio Administrative Code, you may have to reimburse ODM for service payments.
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For technical support or assistance, contact ODM’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for provider enrollment (option 2, option 2) or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.
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OhioRISE is a specialized managed care program for youth with complex behavioral health and multisystem needs. Ohio Department of Medicaid recently published the September edition of the new OhioRISE community newsletter, RISE Together. This newsletter features OhioRISE success stories, care management entity (CME) spotlights, OhioRISE champion stories, program updates, and information on how to enroll in OhioRISE.
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Ohio Department of Medicaid (ODM) and its Ohio Medicaid Enterprise System (OMES) vendors are diligently focused on researching and resolving issues to improve the performance of the OMES system. ODM has addressed the following items:
ODM and its OMES vendors researched and resolved issues impacting 835 Electronic Remittance Advice (ERA) delivery for fee-for-service (FFS) and managed care entity (MCE) claims. An 835 ERA is an Electronic Data Interchange (EDI) transaction that provides claim payment and adjudication information to trading partners. Providers must elect their trading partner to receive 835 ERAs on their behalf.
Fee-for-service 835s
ODM resolved all known issues impacting 835 file delivery for FFS claims. As of August 11, trading partners have received all historical 835 files impacted by the identified issues.
Managed care entities 835s
ODM resolved the following three issues that were resulting in misdirected/missing managed care entity 835s:
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Individual MCE/vendor system issues affected the processing of the trading partner to provider ID mapping extract, resulting in file misdelivery. This issue caused misdirection of some MCE 835s from Anthem, Buckeye, Molina, Humana, and CareSource, affecting up to 1,500 providers. The MCEs/vendor implemented a fix on August 2 and delivered historical 835s impacted by this issue to the correct trading partners.
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CareSource 835 files failed internal compliance and resulted in the non-delivery of files to trading partners. CareSource fixed this issue on July 24 and delivered the final batch of regenerated 835 files to respective trading partners on August 16.
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AmeriHealth misdirected 835s due to a timing issue caused by their virtual credit card payment process. The targeted fix for this issue is later this month.
As a reminder, all payers' .pdf human readable remittance advices are available on the Provider Network Management (PNM) portal. This includes claims submitted to the EDI and the PNM module.
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277CAs for fee-for-service claims
ODM and our OMES vendors resolved an issue related to the 277CA’s missing line level error information for FFS claims. On August 22, ODM released a fix so that 277CAs are delivered with the appropriate service line error information. ODM has asked trading partners to identify the exact error from the information on the 277CA, make the appropriate update, and resubmit a corrected 837 claim.
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On August 15, ODM resolved an issue where claims were being denied due to invalid National Drug Codes (NDC) by updating the NDC list in the OMES system. ODM has asked trading partners to resubmit claims denied prior to August 15 due to invalid NDCs.
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If you have any questions or concerns, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800‐686‐1516 or email IHD@medicaid.ohio.gov. Representatives are available 8 a.m.‐4:30 p.m. Eastern time Monday‐Friday.
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