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As part of Ohio Department of Medicaid's (ODM) effort to modernize management information systems, providers have experienced changes in the claim adjudication process. ODM has received several questions on the credit balance process with fee-for-service (FFS) claims and we would like to give providers some important reminders and clarification.
What is a credit balance?
When a provider owes more to ODM than ODM owes them, the provider has a “credit balance.” When a provider has a credit balance, ODM automatically collects the balance due as a deduction against the provider's future claim payments. If the entire amount owed to ODM is not collected within 150 days, the provider receives a credit balance letter. Depending on where the claim was originally submitted, the process by which the provider pays the balance varies, as described in the following sections.
How do you pay a credit balance?
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If you submit claims through the PNM module via a link to MITS
The Ohio Administrative Knowledge System (OAKS), the State of Ohio's accounting system, pays FFS claims submitted through the PNM module. When a provider has a credit balance for FFS claims submitted through the PNM module, the system reports all claims, claims adjustments, and claims reversals on the 835 and RA for the first possible payment date. The claims and receivables that created the credit balance are also reported in this 835 and RA.
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If you use a trading partner to submit claims
The Fiscal Intermediary (FI) vendor processes and pays FFS claims submitted through EDI on behalf of ODM. When a provider has a credit balance for FFS claims submitted through a trading partner, ODM may hold some new day claims, adjusted claims, and reversals from the first possible payment and from the related 835 and RA. When this happens, the FI offsets the amount in future provider payments.
The FI 835 reports these negative items in the PLB (provider level balance) segment with an adjustment reason code of WU (unspecified recovery) and an identifier that corresponds to the FI’s receivable ID. As of October 26, the FI Claims RA lists each receivable and a corresponding identifier in a recoupments section following the claim detail portion of the RA.
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For additional questions
Additional information on the adjudication process can be found on our updated the Claims and Prior Authorization Submission Frequently Asked Questions. Providers can also 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 - Friday.
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