Submitting Claims and Prior Authorizations
New Resources Available: 271 Code Crosswalk and 271 Acronym Reference Guide
The 271 Code Crosswalk and 271 Acronym Reference Guide are now available for providers and ODM Trading Partners! The 271 Code Crosswalk can be used to help Trading Partners and providers cross reference the 271 eligibility codes with their definitions (e.g. 1019 = CHIP2 QMB) while the 271 Acronym Reference Guide can be used to define acronyms used for the 271 (e.g. MCAID = Medicaid).
February 1 Claims and Prior Authorizations Information
On October 1, 2022 the Provider Network Management (PNM) module began accepting fee-for-service claims and prior authorizations via a redirect to MITS. On February 1, 2023, the Electronic Data Interchange (EDI) launched along with the Fiscal Intermediary (FI) as part of the Next Generation of Ohio Medicaid program. The EDI is the new exchange point for trading partners on all claims-related activities, providing transparency and visibility regarding care and services. The FI facilitates the processing of claims via the EDI. Providers, trading partners, and managed care entities will not directly interact with the FI.
Also beginning on February 1, providers who direct data entry (DDE) managed care claims and prior authorizations will do so through each managed care entities’ portal or other electronic processes.
Additional details about the subsequent changes will be communicated through various channels including the PNM & Centralized Credentialing webpage and the ODM Press newsletter. To subscribe to the ODM Press, please fill out the Subscribe Form and be sure to check the “ODM Press” box.
1. Submitting Claims
Since February 1, all managed care claims submitted by trading partners with a date of service on or after February 1 must be sent to the new Electronic Data Interchange (EDI) and will flow through the FI and then route to the selected MCEs for processing and payment. Providers who submit managed care claims through direct data entry (DDE) will do so via the appropriate Managed Care portal or other electronic processes. Please note, these changes do not apply to MyCare. MyCare providers should continue to submit claims directly to the appropriate payer, either the MyCare managed care plan or Medicare.
For fee-for-service (FFS) claims submitted by trading partners must be sent to the new EDI and will flow to the FI for processing and payment. Providers who submit FFS claims through direct data entry (DDE) will continue to do so through the Provider Network Management (PNM) module via a link to MITS.
Providers wanting to view or edit a claim, must use the same system that was used for the original submission. These systems include MCE portals, MITS page accessed via the PNM module, or through an authorized trading partner utilizing the new EDI portal. For example: if a provider submits a claim via MCE portal, the provider must then use the MCE portal to view or edit their claim. Claims submitted via trading partners are not viewable within the PNM module; however, providers can work with their trading partner to view a claim status.
Subsequently ODM will work on additional changes in the PNM from which providers will benefit from streamlined processes for claims and reduced administrative burden.
2. Submitting Prior Authorizations
Since February 1, all managed care prior authorizations must be submitted to the managed care portal via the applicable managed care entity (MCE) guidance, which may include portal entry or other through another electronic process. For fee-for-service prior authorizations, providers will continue the current process by logging into the PNM module, where, after selecting the "prior authorizations" button, you will be automatically redirected to MITS. Please note, these changes do not apply to MyCare. MyCare providers should continue to submit prior authorizations directly to the appropriate payer, either the MyCare managed care plan or Medicare.
Subsequently, ODM will work on additional changes in the PNM from which providers will benefit from streamlined processes for claims and reduced administrative burden.
3. Pharmacy Claims and Prior Authorizations
As of October 1, the Single Pharmacy Benefit Manager (SPBM) is the entry for pharmacy claims and prior authorizations for managed care members. This does not include members enrolled in a MyCare Ohio plan as well claims for fee-for-service (FFS) members continue to be submitted to the FFS Pharmacy Benefit Administrator, Change Healthcare.
If a member does not have a Medicaid ID card, a pharmacy can verify coverage via the SPBM provider portal or the PNM module with the member’s demographic information. To bill Gainwell, the SPBM Administrator, the pharmacy needs the following information:
- Gainwell RxBIN: 024251
- Gainwell RxPCN: OHRXPROD (note: Gainwell does not require a group number)
- Ohio 12-digit Medicaid member ID (formerly called the MMIS ID). Gainwell will NOT accept a secondary “member ID” assigned by the managed care plans.
- Options to access a Medicaid member ID include viewing the MMIS located on the ID card or digital ID card via the MCO website or app, logging in to the SPBM secure web portal and searching for the member at https://spbm.medicaid.ohio.gov, query Surescripts against Gainwell’s master patient index.
To learn more about Ohio Medicaid’s SPBM, visit the SPBM page on the Ohio Medicaid Managed Care website and visit the Gainwell Technologies SPBM website.
4. Rendering Provider on Professional Claims Submissions
Since February 1, for EDI-related claim submissions, ODM now requires one rendering provider per claim at the header level, rather than the detail level. This requirement applies to professional claims for both fee-for-service (FFS) and managed care enrollees to ensure claims can be properly priced and paid. Examples of claims submissions with the rendering practitioner are as follows:
- A client receives one service during the visit. The rendering practitioner’s NPI is recorded in the header field on the claim. The service is recorded at the detail level on the claim without the rendering practitioner’s NPI.
- A client receives multiple services from the same rendering practitioner during the visit. The rendering practitioner’s NPI is recorded in the header field on the claim. Each service is recorded at a separate detail level without a rendering practitioner NPI.
- The client receives multiple services, each from a different rendering practitioner during the visit. The billing provider must create separate claims for each service provided by each rendering practitioner during the visit. Each claim must record the rendering practitioner NPI at the header level on each claim, and the service they rendered to the client is recorded at the detail level.
There is one exception to this rule for services provided by FFS Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) providers. FQHC/RHC claims submitted to ODM for payment may include multiple rendering providers at the detail level because ODM pays FQHC/RHC providers based on an encounter. In these specific scenarios multiple rendering providers on a claim will not cause a pricing/paying issue because the rendering providers are not utilized in determining payment for FFS FQHC/RHC wraparound claims. For additional guidance related to FQHC/RHC providers, please review the Medicaid Advisory Letter located here: Medicaid Advisory Letter 622.
5. Electronic Data Interchange Module: Seven things You Need to Know
Now that the new EDI has launched, here are few things to check and understand:
1. Check that your trading partner is authorized to work with ODM.
All clearinghouses or trading partners who are already authorized to submit claims to ODM continue to have access to submit claims on behalf of providers – but we encourage these trading partners to practice submitting claims to the new system prior to submitting claims. Providers should validate that their trading partner is authorized to work with ODM and has practiced submitting claims through the new system. Trading partner connectivity can be checked here.
2. Provider claims submitted to trading partners must include the Medicaid member's ID (MMIS ID).
The Medicaid ID should be obtained with each visit. Member eligibility can be verified using the ID through the PNM module, which redirects to MITS.
3. Pay attention to each claim’s date of service when submitting for adjudication.
Since February 1, all FFS claims must be submitted to the new EDI. Managed care organization (MCO) claims with a date of service on or after February 1 must be submitted through the new EDI. MCO claims with dates of service prior to February 1 may be submitted to the new EDI, but providers have the choice to send everything through the new EDI or split claims by dates of service. Please see the ODM Companion Guides for specific instructions and additional guidance.
4. Each managed care claim must include the internal managed care payer ID and a receiver ID.
If you submit your own claims through the EDI, please refer to the ODM Companion Guides for the updated receiver and payer IDs list for the managed care plans. FFS claims also require a payer and receiver ID but they remain the same.
5. For EDI‐related claims submissions, ODM now requires one rendering provider per claim at the header level, rather than the detail level, for professional claims for both FFS and managed care recipients.
Different rendering providers at the detail level are no longer acceptable. Exceptions for FFS Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) providers are detailed in the Medicaid Advisory Letter 622.
6. FFS provider payments from EDI-submitted claims are sent by the Fiscal Intermediary (Gainwell Technologies).
These payments are paid on behalf of Ohio Department of Medicaid. FFS claims submitted through the PNM module will continue to be paid by Ohio Administrative Knowledge System (OAKS), the State of Ohio’s accounting system.
7. Trading partners will not submit attachments on behalf of providers.
All managed care attachments will be handled by each managed care entity (MCE). Providers should work with each MCE to submit attachments following the process outlined by the applicable MCE. For FFS claim attachments, these will be submitted in a MITS portal page accessed via the PNM module.