On September 11, the Ohio Department of Medicaid (ODM) updated how the Electronic Data Interchange (EDI) validates provider status and affiliation. Previously, the EDI checked if the service provider was enrolled with ODM on each claim’s date of submission. Providers must now be found on the ODM Provider Master File to be validated.    

How does this impact claims submitted by trading partners? 

For managed care claims: 

• Managed care claims continue to be forwarded for processing to the respective managed care plan. 
• Managed care plans continue to respond with the applicable 277CA EDI transaction. 

For fee-for-service claims: 

• Fee-for-service claims are now adjudicated based on the date of service, provider enrollment, and member eligibility.  
• If the provider cannot be found in the ODM Provider Master File, meaning they are not enrolled with Ohio Medicaid, trading partners will receive an 824 response. If the provider is enrolled, but inactive on the date of service, an 277CA response will report the appropriate rejections for fee-for-service claims.  

What action do providers need to take? 

Providers must verify their enrollment and affiliations within the Provider Network Management (PNM) module remains current. ODM encourages providers to regularly update information the PNM module to reduce claim denials for inactive provider status or affiliation.  

Providers should wait 48 hours after updating PNM module information before submitting claims. The PNM module confirms enrollment and affiliation, providers can resubmit previously rejected claims.  

Additional Help 

ODM continues monitor error rates within the EDI to streamline the claim submission process. If you need additional help, please contact the ODM EDI Integrated Helpdesk (IHD) at 800‐686‐1516 (option 4) or omesedisupport@medicaid.ohio.gov. IHD representatives are available 8 a.m.-4:30 p.m. Eastern time Monday‐Friday.