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Important provider information: EDI billing updates

Important provider information: EDI billing updates for nursing facilities and intermediate care facilities for individuals with intellectual disabilities

Ohio Department of Medicaid (ODM) performed an update to the Ohio Medicaid Enterprise System (OMES) to improve the processing of Electronic Data Interchange (EDI) submitted fee-for-service (FFS) claims with covered and non-covered days. OMES will now properly deduct share of cost (SOC)/patient liability (PL) from claims for members with a monthly payment obligation toward their cost of facility care. With these changes ODM would like to inform and remind providers of a few important items.

Covered/non-covered days

Fee-for-service claims for covered and non-covered days must be billed with the corresponding value codes and must match the information billed at the detail of the claim. While this has been a requirement since February 1, 2022, it has not been enforced. Going forward, claims without this information or with a data mismatch will be denied for payment.

What do providers need to do about billing covered/non-covered days?

Submit all new and adjustment claims with the correct covered/non-covered value codes. Claims denied due to incorrect value code information must resubmitted as a new claim. Providers and trading partners should verify that appropriate claim submissions include the following value codes:

• 80 - Covered days
• 81 - Non-covered days

ODM is reprocessing recently paid, EDI-submitted claims for non-covered days on behalf of providers. We anticipate this to be completed in January. No additional provider action is needed. Additional important information for covered/non covered billing guidance can be found in the table below. This information is also included in the 837 Institutional Fee-For-Service Claims Companion Guide.

Share of Cost/Patient Liability

EDI claims and claim adjustments now adjudicate by reducing the provider payment by the amount of SOC/PL on file for members with dates of service billed. Providers should continue to bill the amount of SOC/PL they have on file for the Medicaid member on submitted claims. This will be compared to the amount ODM has on file for those members.

If the amount of SOC/PL billed on the claim is not the same as the amount on record with ODM for a member, the remittance advice will report CARC N861. This is to notify providers of the discrepancy between the two amounts. Additionally, in a future system enhancement, OMES will auto-deduct pro-rated SOC/PL from claims where a member was institutionalized for less than a full month.

What do providers need to do about billing Share of Cost/Patient Liability?

ODM is reprocessing EDI submitted claims recently paid without deducting SOC/PL on behalf of providers. We anticipate this to be completed in January. No additional provider action is needed. Additional important information for Share of Cost/Patient Liability billing guidance can be found in the table below. This information is also included in the 837 Institutional Fee-For-Service Claims Companion Guide.

For additional questions

Please refer the 837 Institutional Fee-For-Service Claims Companion Guide on the Medicaid website for complete billing information. For additional help please contact Ohio Medicaid’s Integrated Helpdesk 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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