Next Generation Medicaid managed care organizations (MCO), the OhioRISE plan, and MyCare Ohio plans will use provider data from Ohio Medicaid’s Provider Network Management (PNM) module as it is the official system of record. To ensure the provider data sent from the PNM to the managed care entities (MCE) are accurate, it is important that your records are updated and remain up to date within the PNM module. In the future, if your data in the PNM module does not match your data on the submitted claim, your claims will be denied for payment.

Ohio Department of Medicaid met with key stakeholder associations and their members regarding ODM’s direction to deny claims due to data misalignment between the MCEs’ systems and ODM’s PNM system generated Provider Master File (PMF) beginning on October 20. As a result of the feedback and discussion, ODM has determined that MCEs will not deny claims for PNM System data misalignment at this time. ODM will continue to work with the MCEs to validate the success of using the PMF and based on that success will determine a date in the near future to initiate this process.

What is data misalignment?

Today providers are paid through a combination of data reported directly to MCOs and data provided to ODM. The data reported by the provider to ODM is included in the PMF, which is shared with MCOs daily. When the MCOs data and the PMF data for claims processing disagree, this is referred to as “data misalignment.” The goal is to reduce provider administrative responsibilities by consolidating data management into a single system -- the PNM -- that serves as the source of truth for processing claims across the Medicaid enterprise. ONGOING ACTION REQUIRED: Providers or trading partners

It is essential that providers continue to update their data in the PNM so that the validation testing being done with the plans will be successful. ODM will be moving this change into production and all the work to keep the PNM up to date will ensure there will be minimal impact when it is rolled out.

1. Check that all data submitted on a claim and within the PNM module (e.g., addresses, affiliations, specialties, locations) are accurate and up to date.
2. Access Provider Education & Training Resources within the PNM ‘Learning’ tab for step-by-step instructions.
3. Continue to update provider data as changes occur. MCEs will use this information as the system of record moving forward.

The MCEs download a complete extract of the Provider Master File (PMF) that includes all provider data DAILY.

For more information

For technical support or assistance, contact Ohio Medicaid’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.

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website.

Ohio Department of Medicaid (ODM) resumed provider revalidation notices in June 2023 as part of the federally required unwinding process from the COVID public health emergency. ODM issues a series of notices with the first one delivered 120 days before your Medicaid agreement end date. Subsequent reminders are issued at 90 days, 60 days, and a final notice at 30 days. If you receive a revalidation notice, it is important that you take action to complete your revalidation on time. All providers are subject to either 5-year or 3-year time-limited provider agreements.