What changed for providers and PNM users? 

The new OMES features in the PNM increase visibility for providers of claims submitted by trading partners, streamline fee-for-service (FFS) claims and prior authorizations submission, and improve self-service functions and access to financial documents. The Fiscal Intermediary now processes and adjudicates all FFS claims and prior authorizations. Providers and PNM users can now: 

• Complete direct data entry for FFS claims and prior authorizations, conduct claims searches, and complete other administrative activities in the PNM module without being rerouted to the Medicaid Information Technology System (MITS). 
• Complete claim adjustments and voids in the PNM for any FFS claims, whether they are submitted by direct data entry in the PNM or by a trading partner via the Electronic Data Interchange.  
• Receive one remittance advice for FFS claims whether they are submitted by direct data entry in the PNM or by a trading partner via the Electronic Data Interchange.  
• Find future 1099 forms and other financial documents in the PNM without needing to call the Integrated Helpdesk (IHD). To retrieve 1099 forms for past tax years providers will need to call the IHD.
• Look up member eligibility within the PNM, rather than being rerouted to MITS, which streamlines and simplifies the process.
• Look up hospice enrollment within the PNM, rather than being rerouted to MITS.

What resources are available to assist providers? 

We understand that this is a big change, and we appreciate your contributions that have made the Next Generation program possible. ODM developed resources to help providers with this implementation. We encourage you to read and share the following:

• View the June 30 New Features Implementation Overview document to learn what this change means for providers and PNM users. This document also includes information about where providers should go for questions about OMES-submitted claims, prior authorizations, and other administrative processes.
• View the Who to Contact for Help resource to learn who providers should contact if they need assistance. Most questions about this implementation should be directed to the Integrated Helpdesk at (800) 686-1516.
• Review the June 30 New Features Implementation Frequently Asked Questions (FAQ) document for answers to some of the most common questions about the implementation.
• Review the PNM module FAQ document for more information on PNM functionality.  
• Visit the Implementation Training and Resources page on the Next Generation website to learn more about training, and other available resources.

Do you have questions? 

If you have questions related to OMES-submitted claims, prior authorizations, or other administrative processes, contact the IHD at 800-686-1516 or IHD@medicaid.ohio.gov. The IHD is open Monday-Friday, 8 a.m.-4:30 p.m. Eastern time. 

The Ohio Department of Medicaid (ODM) is aware of two issues related to prior authorization submission in the Provider Network Management (PNM) module.

Diagnosis Code Issue – No action needed

Some PNM users received an error when trying to submit prior authorizations July 1 - 2. The error code PNM users received follows:

FAILURE: Unable to submit the transaction. Please try again if the problem persists please call 800-686-1516, option 1.

This problem occurred because PNM users typed a decimal in the Prior Authorization Diagnosis (PA DX) field. PNM users must now enter a valid diagnosis code, without any decimal points, to proceed in the prior authorization process. If a PNM user enters a decimal point in the PA DX field, they will receive an error message and must correct the issue before moving forward.

ODM resubmitted prior authorizations affected by this issue to the Fiscal Intermediary for processing on July 2. PNM users do not need to take additional action.

Missing National Provider Identifier – Action needed

ODM also found an issue with an error message on PA submissions. The error message about missing national provider identifier (NPI), which reads “Missing NPI,” should have included instructions on resolving the issue. We have now added following guidance in the PNM module:

• If you receive this error, you must enter an Individual or Facility Provider NPI in the Service Provider field.

• You cannot enter a Group Provider NPI in this field.

• Special Note for durable medical equipment PAs you can enter an Individual NPI or Group NPI.

• However, the Ordering Provider must be an Individual NPI.

If you have not received a prior authorization status for a prior authorization submitted July 1 and July 2, please resubmit the prior authorization in the PNM module.

For additional Help

For additional help or questions, contact 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. Thank you for your continued partnership and support of the Next Generation Ohio Medicaid program.

In May, we announced the release of the Next Generation MyCare Request for Applications (RFA). This RFA is for managed care entities interested in becoming Next Generation MyCare managed care plans for Ohioans who are dually eligible for Medicaid and Medicare. The selected plans will be an essential piece in improving the health and lives of Ohioans. This RFA remains open until Wednesday, August 7, and we encourage all eligible managed care entities to apply.

All potential applicants were required to notify ODM of their intent to submit a response by June 26 at 4 p.m. ET. Managed care applicants who notified ODM of their intent to submit by June 26 deadline are currently eligible to apply. Further details are noted in the RFA.

Like any procurement of this size, this procurement has significant guardrails regarding communications about the procurement and the program.

ODM must adhere to federal and state procurement requirements and appropriate safeguards to ensure a fair process and reduce the risk of post-award challenges. As a result, ODM cannot:

• Share details related to RFA content, release certain dates, timelines, responses received, and/or award prior to official public announcements.
• Communicate design discussions and decisions related to the MyCare structure beyond what is stated in the RFA.

At this point in time, ODM is in the “quiet period” for the Next Generation MyCare procurement, which dramatically limits the information available to share on an individual basis. All information ODM releases regarding the Next Generation MyCare procurement must be at equal opportunity of access for potential bidders, preventing any compromise of the procurement.

It is ODM’s commitment to remain as communicative and transparent as possible through the remainder of the procurement process, while still maintaining the integrity of the Next Generation MyCare procurement. ODM will not be able to answer questions from members of the public or potential bidders regarding the Next Generation MyCare program, but general updates and announcements will be posted on the MyCare Ohio webpage on Medicaid.ohio.gov.

Resources on procurement regulations can be found in the State of Ohio Procurement Manual.

For additional information about the RFA or procurement process, visit the MyCare Ohio webpage on Medicaid.ohio.gov.