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What You Need to Know

Who to bill for physical health services provided to OhioRISE enrollees

Ohio Resilience through Integrated Systems and Excellence (OhioRISE) is an Ohio Medicaid managed care program offering specialized behavioral health services to children and youth with complex multisystem behavioral health needs. Since its July 2022 launch, nearly 20,000 children have been enrolled into OhioRISE behavioral health supports as well as Ohio Medicaid’s traditional physical health services.

If you are a provider supporting OhioRISE enrollees, we want to ensure you know who to bill for the non-behavioral health services they receive. Invoicing for physical health services offered to OhioRISE enrollees is determined by which Medicaid health program they’re enrolled in: managed care or fee-for-service (FFS).

First, verify the enrollee’s main healthcare program

You can check whether the child or youth you are serving is enrolled in Medicaid’s managed care or FFS program by taking any of the following three actions:

  1. Log into MITS through the Provider Network Management (PNM) module and conduct a recipient search using the child or youth’s information. If you need help, check out the Accessing MITS Secure Portal from PNM Quick Reference Guide.
  2. Call Ohio Medicaid’s 24/7 Integrated Helpdesk at 800-686-1516. Representatives are available 8 a.m.-4:30 p.m. Monday-Friday, ET.
  3. Check the member’s Medicaid ID card and look for the OhioRISE logo. Be sure to check both the front and back of the card. You can find an example of our member ID card on our Welcome Provider website page.

Next, identify the appropriate billing entity

Once you determine which Medicaid health program your OhioRISE client participates in, use the information below to identify the appropriate billing entity:

  • If a youth or child is on Medicaid’s managed care program:
    • Physical health services should be billed to their MCO.
    • Pharmacy services should be billed to the Single Pharmacy Benefit Manager, Gainwell Technologies.
  • If a youth or child is on Medicaid’s FFS program:

An inpatient hospital admission with a primary diagnosis of mental illness or substance use disorder (SUD) results in enrollment in the Ohio Resilience through Integrated Systems and Excellence (OhioRISE) program for individuals under 21 years of age. The process to get an approval for this service may cause confusion with providers. To help reduce questions and ease administrative burden on providers, the prior authorization (PA) process for inpatient psychiatric or SUD stays must be coordinated between our managed care partners and the OhioRISE plan, Aetna.

After soliciting and reviewing information from each MCO on their inpatient psychiatric and SUD prior authorization and transition of care processes, ODM determined a single approach for this process across all MCOs would be beneficial for all involved parties.

Recommendation

Aetna will not have the ability to accept prior authorization requests in their (Availity) prior authorization system until a member’s OhioRISE enrollment has been received on the 834 and is loaded into their system, but Aetna’s UM team will support the submission of PA requests for pending members. For this specific reason, ODM has outlined the following process for both the MCOs and Aetna to use to obtain prior authorization for inpatient hospital psychiatric or SUD admissions for youth and children under age 21 that would result in the stay being the OhioRISE plan’s responsibility, in accordance with the OhioRISE Mixed Services Protocol.

When the prior authorization request is received at the MCO for an inpatient hospital psychiatric or SUD admission for individuals under age 21 not yet enrolled in the OhioRISE plan, the MCO will:

  1. Contact the hospital to provide the following information:
        a. Notify the hospital the prior authorization will be denied by the MCO, because the stay is the responsibility of Aetna.
        b. Share the following information about how the hospital may submit the PA to Aetna until the member is formally enrolled and is visible in all systems:
            i. Aetna’s Fax # for inpatient hospitalizations is 855-948-3774
            ii. Aetna’s Provider Hotline number is 833-711-0773 (option 2)
            iii. Aetna transition of care coordinators may be reached             at OhioRISETOC@aetna.com
        c. Inform the hospital of the importance of entering the psychiatric or SUD inpatient stay notification in the CANS IT system for prompt enrollment and so claims can be submitted to Aetna.
        d. Inform them that Aetna will be reaching out to them to help coordinate the transition of care through inpatient stay.
  2. Once the hospital has been informed the prior authorization will be the responsibility of Aetna, the MCO will deny the prior authorization request and send a notice of action (NOA). Although the individual is not yet reflected in the system as enrolled in OhioRISE when issuing the denial, the denial should indicate the service is being denied because it is the responsibility of another managed care entity to pay for the service.
  3. Contact Aetna’s Transition of Care Coordinator to inform them of the prior authorization request, ensure entry of the notification of the psychiatric or SUD admission in the CANS IT system and share any documentation related to the PA request that was submitted by the hospital, as agreed upon in the Model Agreement.
  4. Provide Aetna’s Transition of Care Coordinator with the contact at the hospital.

After receiving notification of the inpatient psychiatric or SUD admission, Aetna will follow up with the hospital to provide additional instructions on how to complete the prior authorization for review. Aetna will work with the hospital and MCO to support and coordinate transitions of care and ongoing care, and to ensure the psychiatric or SUD inpatient notification has been entered in the CANS IT system.

If the primary diagnosis on the prior authorization request initially indicated Aetna would be responsible for the claim and Aetna authorized the service, and later changes in care delivery result in the APR-DRG becoming the responsibility the MCO per the OhioRISE Mixed Services Protocol, the MCO must accept the prior authorization approval issued by Aetna and may not require an additional prior authorization request from the provider. If the reverse is true, Aetna must accept prior authorization approvals from MCOs in situations where the MCO first authorized the service, but the final claim’s primary diagnosis and reimbursement APR-DRG identify the claim as Aetna’s responsibility, in accordance with the OhioRISE Mixed Service Protocol.

If you have any questions regarding this process, please contact OhioRISEpolicy@medicaid.ohio.gov.

Effective for dates of service January 1, 2023, and after, ODM will be increasing the payment rate for CANS assessments. The updated rates will be reflected in the revised Appendix to OAC rule 5160-27-03, the Medicaid Behavioral Health Provider Manual and the OhioRISE Provider Enrollment and Billing Guidance prior to January 1, 2023.

OhioRISE Provider Enrollment During System Transition

(Aug. 1, 2022-Sept. 30, 2022)

In preparation for the Oct. 1 launch of the new Provider Network Management (PNM) module, which will reduce administrative burden on providers, ODM will not accept new provider enrollment applications through the MITS Provider Enrollment System starting Aug. 1. 

See the July 29: OhioRISE Provider Enrollment During System Transition Guidance document.

Submitting claims to Aetna OhioRISE for RISE covered services, and all other services to Buckeye,  Mixed Services Protocol documentation should be referenced.

Denials of claims to OhioRISE on Buckeye remittances will include CARC 301; RARC N216.  Aetna OH Rise will be identified as the payer on the provider’s 835 remittance advice.

OhioRISE (Resilience through Integrated Systems and Excellence) | Ohio Medicaid Managed Care

 

Effective 7/1/22, all youth that experience a psychiatric or substance use disorder inpatient admission with a principal behavioral health diagnosis will be automatically enrolled into OhioRISE on day 1 of the admission.

  • The behavioral health diagnoses include the following codes: F0150-F99, R440-R443, R450- R4582, R45850-R4589, R4681-R4689, or Z72810-Z72811.
  • The reimbursement DRGs include the following: 740, 750-760, 770 or 772-776.
  • An inpatient claim type with a principal diagnosis code or reimbursement DRG outside of the behavioral health range is the responsibility of Buckeye.
  • Notes:
  • If the individual turns 21 during the psychiatric inpatient stay, the OhioRISE Plan is responsible for the hospital claim (admit through discharge)
  • If individual is transferred to/from medical to/from distinct part psychiatric unit, the psychiatric stay is billed to the OhioRISE Plan and medical is billed to the individual’s MCO (or FFS).
  • Three-day roll-in: If individual is enrolled in OhioRISE at the time of the outpatient visit and there is a subsequent psychiatric inpatient admission at the same hospital, the outpatient visit will be rolled into the inpatient admission; if not already on the OhioRISE Plan and has a subsequent psychiatric inpatient admission, the individual’s MCO (or FFS) is responsible for the outpatient services (services billed as OPHBH at general hospitals are excluded from the three-day roll-in).

Aetna OhioRISE Claims - Practitioner Modifiers Update

This MITS BITS provides an update to and replaces the communication sent on June 16, 2022, regarding the use of practitioner modifiers on Aetna OhioRISE claims submitted by community behavioral health providers.

In preparation for the launch of OhioRISE on July 1, 2022, and in preparation for the Ohio Department of Medicaid’s (ODM’s) implementation of the “front door” for claims submission later this year, ODM and Aetna Better Health of Ohio have agreed to align OhioRISE practitioner modifier requirements for outpatient and professional claims with those used in ODM’s fee-for-service program.

In accordance with this set of changes, the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page, were updated today. Both documents now describe Aetna’s practitioner modifier requirements for outpatient and professional claims as aligning with those in ODM’s fee-for-service program.

With the implementation of this update in Aetna’s billing requirements, Aetna will NOT REQUIRE practitioner modifiers on the following types of claims, unless the rendering practitioner holds multiple licenses or credentials with differing scope of practice (see section below).

  • Community mental health agency claims (provider type 84).
  • Community substance use disorder treatment provider claims (provider type 95).
  • OhioRISE care management entity (CME) claims.
  • Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
  • Outpatient hospital claims submitted for Enhanced Ambulatory Patient Groups (EAPG) reimbursement.

In alignment with ODM fee-for-service policy, Aetna will require practitioner modifiers on outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement. Aetna’s OPHBH practitioner modifier requirements will mirror ODM’s fee-for-service requirements.

Practitioners with multiple licenses or credentials

Aetna will require rendering practitioners holding multiple licenses or credentials with differing scopes of practice to use ODM’s requirements for enrollment and claims submission, including:

  • Provider enrollment with a multi-license specialty.
  • Rendering provider reporting their additional licensure/credentials on claims.
  • Use of modifiers identified on ODM’s dual licensure grid, which can be found on https://bh.medicaid.ohio.gov/manuals.

Aetna will be reconfiguring its claims engine to incorporate the requirements outlined above. Until this reconfiguration is complete, Aetna will need to process some claims manually. Providers will not be required to resubmit or adjust claims at a later date if their claims are processed manually because of Aetna’s reconfiguration timeline.

As noted in a previous MITS BITS, other changes were made to the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity Manual on June 14, 2022, including some clarifying language and corrections made based on stakeholder feedback. Those changes are noted in the version logs at the beginning of each document.

The Medicaid Behavioral Health Provider Manual was also updated on 6/14/2022 to clarify that CANS assessments must be entered in Ohio’s CANS IT system only to establish and maintain OhioRISE eligibility.

Questions?

___________________________________________________________________________

June 16, 2022

In preparation for the launch of OhioRISE on July 1, 2022, the Ohio Department of Medicaid and Aetna have made some changes to the OhioRISE Provider Enrollment and Billing Guidance and the Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page. Changes were made to include a practitioner modifier table and to clarify Aetna’s practitioner modifier requirements for professional and outpatient claims.

Practitioner modifiers are REQUIRED by Aetna on the following claims, for each service line and all practitioner types: 

  • Community mental health agency claims (provider type 84).
  • Community substance use disorder treatment provider claims (provider type 95).
  • CME claims for CANS and initial comprehensive assessment services only (CMEs do not use practitioner modifiers on ICC/MCC claims).
  • Outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement.

Practitioner modifiers are NOT REQUIRED by Aetna for the following claims: 

  • CME claims for Intensive Care Coordination and Moderate Care Coordination (see the updated OhioRISE CME Manual for more information, practitioner modifiers are NOT allowed on ICC/MCC claims, but CMEs should use them on claims for CANS and comprehensive assessments).  
  • Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
  • Outpatient hospital claims submitted for Enhanced Ambulatory Patient Group (EAPG) reimbursement.

To allow providers additional time to configure claim systems to accommodate Aetna’s practitioner modifier requirements, Aetna is offering a grace period for practitioner modifier use. 

For claim submission dates from July 1, 2022, until Aug. 15, 2022, providers have three options:  

  • Option 1: Providers may submit claims requiring practitioner modifiers using the practitioner modifiers defined in the updated billing guidance document. 
  • Option 2: Providers that need additional time to configure their claims systems may submit claims to Aetna without practitioner modifiers during the grace period. For claims that would otherwise deny because no practitioner modifier is included, the claims will be pended during the grace period and Aetna will process manually. Providers using this option will not be required to resubmit or adjust claims at a later date to add practitioner modifiers.  
  • Option 3: Providers may hold claims and submit to Aetna after their systems are configured to include the practitioner modifiers where required, as long as timely filing requirements are met. Aetna accepts claims for 365 calendar days from the date of service.  

Other changes also have been made to the OhioRISE Provider Enrollment and Billing Guidance and the Care Management Entity (CME) Manual, including some clarifying language and corrections made based on stakeholder feedback. These changes are noted in the version logs at the beginning of each document.  

The Medicaid Behavioral Health Provider Manual also has been updated to clarify that CANS assessments must be entered in Ohio’s CANS IT system to establish and maintain OhioRISE eligibility.

Questions regarding OhioRISE may be submitted to the support mailbox: OhioRISE@medicaid.ohio.gov.  

Questions regarding Medicaid Behavioral Health Policy may be submitted to
Bh-Enroll@medicaid.ohio.gov. 

In preparation for the launch of OhioRISE on July 1, 2022, the Ohio Department of Medicaid is providing OhioRISE provider enrollment and billing guidance.

The OhioRISE program covers a range of behavioral health (BH) services for youth that are comprised of existing, enhanced, and new behavioral health and care coordination services. This guide is intended to share policies related to billing for the new and enhanced OhioRISE services. Existing behavioral health services will be covered in accordance with the OhioRISE Mixed Services Protocol and will be billed consistent with the billing policies outlined in the appropriate provider type billing guidelines.

You can find the guidance on the OhioRISE website and here OhioRISE+Provider+Enrollment+and+Billing+Guidance.pdf.

A message from ODM:

As a result of feedback from MCEs and providers, ODM would like to share that the OhioRISE Mixed Services Protocol was updated December 8, 2022, to provide clarity around Managed Care Organization (MCO) or OhioRISE plan responsibility for behavioral health services for youth enrolled in the OhioRISE plan. Updates were made to assist providers and MCEs in determining to which entity claims should be submitted, particularly for services rendered in Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC).

The OhioRISE Mixed Services Protocol defines financial responsibility for services that may be covered by either the MCO or the OhioRISE plan and is available on the Resources for Community Partners and Providers page.

Effective for dates of service January 1, 2023, and after, ODM will be increasing the payment rate for CANS assessments. The updated rates will be reflected in the revised Appendix to OAC rule 5160-27-03, the Medicaid Behavioral Health Provider Manual and the OhioRISE Provider Enrollment and Billing Guidance prior to January 1, 2023.