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How can I start the provider claim dispute process?
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Where can more information be found about each MCE?
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What is the typical timeframe for a claim dispute resolution?
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Who can I contact for questions at the MCE?
Providers are encouraged to use this resource and share it with their colleagues. Please note this resource does not include information on MyCare Ohio plans.
Additional managed care entity reimbursement information
MCEs are not required to reimburse providers who do not have a contract or a provider reimbursement agreement in place of a contract. Providers who are not contracted with an MCE but authorized under agreement with the MCE to provide service to its members must ensure they have a written, and mutually agreed upon, compensation schedule before rendering services.
MCEs may deny claims for coordination of benefits (primary insurance) because Medicaid, including a Medicaid-contracting MCE, is generally the payor of last resort. Exceptions include services provided under Title V and similar programs outlined in OAC 5160-26-09.1. MCEs must provide coordination of benefits as outlined in the rule. If the MCE denies a claim for coordination of benefits and the patient denies having primary insurance, please contact the MCE's customer service/regional provider relations representative to obtain further information regarding the primary payer.
It is up to the provider to establish a noncontracted reimbursement agreement (i.e., single case agreement) with the MCE to continue seeing an MCE's members if the provider still needs to complete contracting and credentialing. MCEs are not required to contract with every provider. In most situations, providers are prohibited from billing the member directly, even if the MCE denies reimbursement to the provider and the provider chooses to continue seeing the member.
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If providers have any questions or concerns, please see the contact information for each MCE in the Claims Denial Resource Grid. Providers can also 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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Ohio Department of Medicaid, in partnership with Maximus, the Provider Network Management (PNM) module vendor, is excited to share that we are continuing our provider awareness and training efforts. Training is scheduled for February 6 –15, and the PNM and Centralized Credentialing page. Below, you will find how to register for sessions and a list of topics covered in each.
Registration steps for enrolling through the learning management system
Access the Absorb learning management system to register for the training. If you do not have an Absorb account, you must create one to access all training sessions, answer forms, and view various PNM module resources. For help, please see our job aid and follow the steps to create your account and/or register for training.
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Provider Administrator User (PNM Dashboard/Homepage).
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Provider Administrator User (Application).
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Provider Agent User.
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Updating/Managing Affiliations.
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Updating Individual Practitioner Records.
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Updating Group/Organization Records.
- Maintaining Behavioral Health Provider Records.
Note: Additional session details are available within the Absorb course listing.
To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. If you are experiencing technical issues accessing the PNM module or have specific questions, please contact the ODM Integrated Helpdesk at 800-686-1516 or IHD@medicaid.ohio.gov. The ODM Integrated Helpdesk is open 8:00 a.m.-4:30 p.m. Monday-Friday, Eastern time.
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Ohio Department of Medicaid’s OhioRISE program is a specialized managed care program for youth with complex behavioral health and multisystem needs. If you have patients or families that need more information about the OhioRISE program, point them to the Resources for Members and Families webpage which has everything they need to know!
Who can benefit from the OhioRISE program?
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Have multiple needs that result from behavioral health challenges.
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Have multisystem needs or are at risk for deeper system involvement.
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Are at risk of out-of-home placement or are returning to their families from out-of-home placement.
Who is eligible for the OhioRISE program?
Children and youth who may be eligible for OhioRISE must meet each of the following criteria:
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Ohio Department of Medicaid (ODM) resumed provider revalidations on October 1, 2023. Since then, ODM has seen an increase of provider specialty discrepancies, especially among the Physician/Osteopath Individual provider type. Because of this, providers are strongly encouraged to review the provider specialty page in the Provider Network Management (PNM) module for accuracy.
Verifying that information is current and complete is especially important for providers who require credentialing. It enables ODM’s Credentials Verification Organization to complete credentialing for providers, ensuring each has the appropriate education and training for active specialties as listed on the Specialties page. Providers who are denied credentialing cannot be enrolled in the Ohio Medicaid program.
ODM provides the information on the Specialties page of the PNM to the managed care plans to use for their provider directories.
What action do providers need to take?
Review the PNM Specialties page during your revalidation/reenrollment process to make any updates or adjustments to the active practicing specialties. Please note, the “200 Physician/Osteopath Individual” specialty type is no longer a valid specialty and would require an update to add the correct specialty in PNM. See the Specialty Quick Reference Guide for instructions. Additional instructions are included below if an inaccurate specialty is designated as “Primary”.
Please confirm that the specialty designated as “Primary” on the PNM Specialties page is accurate. As shown in the image below, the primary specialty will have a “Yes” under the Primary column. If it is inaccurate another specialty will need to be assigned as the primary before making changes to the inaccurate specialty. The steps below outline the process for you:
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To update your primary specialty, add the correct specialty before end-dating the inaccurate specialty by clicking the "Designate a Primary Specialty" box as shown below.
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- Under the "Edit" tab go to the inaccurate specialty and click on the pencil icon to correct. A drop-down section will appear to allow edits. If a change is needed, a new end date must be entered, replacing the current date of 12/31/2299.
- Save changes and click "Submit for Review" to confirm the update.
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