Ohio Department of Medicaid (ODM) understands that since the February 1, 2023, launch of the Electronic Data Interchange (EDI) providers have experienced issues with the claim submission process. ODM acknowledges this and is working diligently with its vendors to resolve system challenges and improve the provider experience.
As a result, ODM is issuing a limited exception to timely filing requirements for fee-for-service and managed care claims submitted through trading partners via the EDI and subsequently processed in the Fiscal Intermediary. This exception applies to claims impacted by EDI related submission delays and does not include MyCare claims. If providers submit EDI claims that are older than 365 days and have a date of service or inpatient discharge date of January 25, 2022, or later, they will be considered timely if submitted on or before September 30, 2024. However, claims submitted within this window must include the appropriate Delay Reason Code in the specified field below.
You should select the CLM 20 Delay Reason using the following guidance:
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A – Delay Reason Code = 7 (Third Party Processing Delay). Use this code if the claims could not be submitted through the system at all.
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B – Delay Reason Code = 9 (Original Claim Rejected). Use this code if the original claim was submitted, but it could not be processed through the OMES system at that time.
Although ODM is issuing a limited exception to timely filing requirements, claims submitted after the standard 365-day limit are still subject to post payment review. ODM may verify evidence of system submission issues, such as reviewing past Integrated Helpdesk (IHD) call logs to verify that providers attempted to troubleshoot their issue. If issues are not evident, the claim payment may be reversed.
For any other dates of service or discharge dates, the timely filing requirements and exceptions in Ohio Administrative Code rule 5160-1-19 still apply. If you wish to dispute a claim payment or denial, for fee-for-service claims you should submit the Medical Claim Review Request (i.e. form 6653) and for managed care claims follow the appropriate managed care organization's appeal process.
For claim assistance, contact the Ohio Medicaid IHD, option 1, or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.
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On Wednesday, Feb. 21, Governor Mike DeWine held a press conference with Ohio Department of Aging Director Ursel J. McElroy to announce launch of the new Ohio Nursing Home Quality Navigator – an all-in-one online resource for Ohioans seeking nursing home care.
The Navigator – which is now online at Aging.Ohio.Gov/Navigator – provides users with detailed information about every nursing home across the state in one convenient digital location. The tool is free and is available by computer, smartphone, or tablet.
The Navigator allows Ohioans to find nursing homes in their area by searching for their city, town, or zip code. Entering these search terms will generate a map of that area and highlight the nursing homes within a range of anywhere from five to 100 miles. Ohioans can then see a list of those nursing homes and select one for further details about that facility.
Data available for each facility includes its number of beds, its Centers for Medicare and Medicaid Services (CMS) Five-Star Quality Rating, resident and family satisfaction survey scores, staffing data, and other information provided by the facility, such as whether it allows pets, alcohol, or smoking, any religious affiliation, and what special care services it might offer. Users can select multiple nursing homes and view a side-by-side comparison in multiple categories.
The Navigator also provides each nursing home’s phone number and website and includes an instant share feature, allowing users to text or email facility contact information to their loved ones with the click of a button.
The Navigator is the result of the work of the Ohio Governor’s Nursing Home Quality & Accountability Task Force, a group of leading experts in the fields of aging, health care, and long-term care, organized by Governor DeWine to study opportunities to improve all stages of the nursing home journey. This tool represents a new opportunity for Ohioans to get accurate, up-to-date information about their long-term care options quickly and conveniently, without having to search through multiple websites.
For more information about the Navigator, visit the Ohio Department of Aging’s website at Aging.Ohio.gov/Navigator.
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