Attention providers: exciting changes to Ohio’s Medicaid program effective February 1

The Next Generation managed care plans, new Electronic Data Interchange (EDI) module, and Fiscal Intermediary (FI) have been implemented. With the launch of the new EDI and FI, there are some activities for providers that have stayed the same and some that have changed.

Claims and prior authorization (PA) submitted through a trading partner

What are the key changes on February 1?

  • ODM’s new EDI begins accepting trading partner fee‐for‐service (FFS) and managed care claims.
  • Provider claims submitted to trading partners must include the Medicaid member ID (MMIS).
    • Medicaid ID should be obtained with each encounter.
    • Member eligibility can be verified using the ID through the Provider Network Management (PNM) module, which redirects to MITS.
  • For professional claims, only one rendering provider is allowed per claim. Individual claims must be submitted for services rendered by different providers. (See exceptions for federally qualified health centers and rural health clinics in “Rendering Provider on Claims Submissions.”)

What is not changing February 1?

  • FFS PAs will continue to be submitted through the PNM module link to MITS.
  • Managed care PAs will continue to be submitted to each plan using their existing processes.
  • The new EDI will not accept PAs of any kind.

Portal submitted claims and all prior authorizations

What are the key changes on February 1?

  • All Next Generation plans will have portals for direct data entry and providers should consult their provider handbook for instructions on how to bill using the portal.
  • FFS claims will continue to be submitted through the PNM module link to MITS.
    • MMIS ID will be the identifying number used for FFS claims processing.

What is not changing February 1?

  • Continue using managed care plan portals to direct data enter claims and PAs.
  • Plan eligibility will continue to be accessed through MCO portals.
  • Continue using the PNM module, which redirects to MITS, as you do today to submit, adjust, and search FFS claim and PA information. 

The Next Generation managed care plans changes do not apply to MyCare Ohio plans, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.

For additional information and resources about the February 1 launch, visit the provider resources webpage of the Next Generation website.

Help desks are available to assist providers:

  • If you have questions about streamlined claims, prior authorizations, administrative processes, the PNM module, OH|ID, or portal password support, contact the ODM Integrated Help Desk (IHD) at 1-800-868-1516 or IHD@medicaid.ohio.gov.

For billing and prior authorization guidance, contact Provider Services at 1-833-644-6001.

February1 launch of the Next Generation of Ohio Medicaid Program

Providers