Next Gen Contract Information

Important reminder: update addresses and affiliations in the Provider Network Management module

Please update and maintain all addresses and practitioner affiliations in the Provider Network Management (PNM) module on a regular basis to keep all information current. This information is required by the provider agreement.

The benefit of regularly maintaining current provider information in the PNM module is that providers do not have to update this information with each of the MCEs. ODM provides a daily file of all provider data to each MCE and requires them to use the most up-to-date information for billing and directory purposes.  

What action do I need to take?

It is imperative that providers make a concerted effort to update all information in the PNM so that claims payments, provider directories, and network adequacy measurements are not negatively impacted.   

Below are links to PNM Quick Reference Guides with step-by-step instructions on how to complete these actions. Address updates and practitioner affiliations are both self-service features of the PNM and do not require an ODM enrollment specialist to review.   

• Updating or Adding Owner Information 
• Updating or Adding Practice Locations 
• Updating or Adding a Specialty in PNM

For more information  

For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. ET Monday-Friday. 

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing webpage on the Next Generation website. 

New care coordination roles help members

With the launch of Next Generation managed care plans offer more care coordination services to help members navigate their care. More services means additional specialized staff support, including four care coordination roles: care manager, care manager +, care guide, and care guide +. 

• The care guide assists members with short-term goals and one-time needs. 
• The care manager assists members with long-term goals and more complex needs. 

When a member has additional community supports through enrollment in a home- and community-based waiver, a comprehensive primary care practice, or the OhioRISE plan. These community supports are referred to as care coordination entities (CCE) or care management entities (CME) and provide care in addition to care coordination services provided through each managed care organization (MCO). Care coordination staff at MCOs support collaboration between the member, the plan, and the CCEs and CMEs. 

• The care guide + works with CCEs and CMEs to support short-term needs and proactively avoid gaps in care. 
• The care manager + works with CCEs and CMEs to support a member’s long-term, intensive needs. 

Note: the Next Generation managed care plan changes do not apply to MyCare Ohio plans.

Providers can encourage members to reach out to their MCOs directly to learn more about care coordination. For additional information and resources from ODM, refer to the care coordination webpage. 

Buckeye Health Plan’s Care Guides help members access and navigate community resources for help with needs such as finding a doctor, housing, transportation, and durable medical equipment, among other necessities. They also assist Buckeye members with questions related to their health care, their community involvement, and their overall well-being and ensure members are connected with and receiving resources to which they are entitled. A great aspect of the Care Guide program is that each member is assigned to their own personal care guide and act as liaisons between Buckeye and providers of health care to Buckeye members. Our member website page includes further information.

Register now for Provider Network Management module refresher training

Learning management system registration

Absorb, the learning management system (LMS), is where you can access virtual and self-paced training sessions. If you do not have an account in the LMS, it’s important that you create one to access all training sessions, answer forms, and view a variety of PNM module resources. Access the job aid and follow the steps to create your account and register for training.

Training agenda

Training module topics include:

• Account Administration and Dashboard. 
• New Enrollment. 
• Affiliations. 
• Updates & Revalidations.

For more information

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. If you are experiencing any technical issues accessing the PNM module or have specific questions, please contact the ODM Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. The IHD is open 8 a.m.-4:30 p.m. Monday-Friday, Eastern time.

Ohio Department of Medicaid (ODM) is issuing an update to providers and trading partners regarding the temporary redirection of Electronic Data Interchange (EDI) claims from the Ohio Medicaid Enterprise System (OMES) to the Next Generation Medicaid Managed Care entities (MCE).

Based on recent trends with successful transmission rates, ODM has determined the direct submission of claims by trading partners to MCEs is no longer needed and would create an inconsistent provider experience across MCEs. As a result, ODM is not approving any trading partner to submit EDI claims directly to the MCEs. Fee-for-service (FFS) and managed care EDI claims should continue to be submitted directly to the OMES EDI vendor, Deloitte. ODM’s analysis of the OMES has determined that redirection of EDI claims directly to the MCEs would not alleviate the challenges providers are facing with claims payment as many of these issues are related to providers’ FFS claims.

ODM is taking several additional steps to improve the FFS payment rate. Edits within the Fiscal Intermediary (FI) are being relaxed to ensure claims accepted by the EDI system are not rejected by the FI system. Claims previously rejected by the FI due to edits that are being relaxed will be reprocessed automatically and do not need to be resubmitted. For trading partners with lower acceptance rates, ODM is examining errors to identify common causes and provide specific guidance to improve the successful transmission of claims. ODM is also carefully monitoring suspensions, denials, and payment rates to ensure consistency with historic standards.

This update does not impact provider eligibility for temporary bridge payments. Providers and/or trading partners do not need to attempt to submit EDI claims directly to the MCEs to qualify for bridge payments. The ability to send EDI claims directly to an MCE has not been, and will not be, taken into consideration when ODM reviews data to determine eligibility for bridge payments. In accordance with the guidance issued previously by ODM, trading partners do need to be actively working with OMES EDI to be eligible for bridge payments.

Trading partners are encouraged to continue to actively submit claims to the OMES EDI.

Providers and/or trading partners experiencing EDI claim issues should contact ODM’s Integrated Helpdesk (IHD) at 800-686-1516. 

Questions regarding this communication should be sent to ODMBridge@medicaid.ohio.gov.

The Ohio Department of Medicaid has been made aware of a current scam, where callers are stating the member will lose Medicaid coverage if the member doesn’t pay hundreds of dollars to the scammer. There are also similar scams for other benefits, including SNAP. ODM would never call anyone asking for money. Please be sure to notify your staff and patients of this potential risk.

Information about ODM resuming Medicaid eligibility operations is available here: https://medicaid.ohio.gov/stakeholders-and-partners/covidunwinding/covidunwinding.

Temporary redirection of claims from Ohio Medicaid Enterprise System to managed care entities

Ohio Department of Medicaid (ODM) will temporarily approve ACTIVE trading partners that are having challenges with the Ohio Medicaid Enterprise System (OMES) to submit Electronic Data Interchange (EDI) claims directly to the managed care entities (MCE) for all claims regardless of dates of services. Fee-for-service (FFS) claims will still need to be submitted to Deloitte EDI.

ODM is working with MCEs to confirm the ability to successfully receive claims directly from the active trading partners and expects to follow up in two weeks with additional information regarding the temporary change. In the meantime, trading partners are encouraged to continue submitting managed care claims via OMES.

Important things to note:

1 – Trading partners do not need to establish new connections to OMES or the MCEs. If you send your claims to another entity that connects to OMES or the MCEs that relationship does not need to change. The entity that submits the claims to OMES/MCEs will be the one potentially permitted to revert to the previous submission path.

2 – Prior to February 1, trading partners did not connect directly with the MCEs but rather to their designated vendors such as Availity or CHC. A new submission route does not need to be created. These entities will change the dates of services and trading partners that will be accepted by them.

Communicating with Billing Providers

To ensure widespread awareness of upcoming changes and per ODM direction, Buckeye is sharing a February 27, 2023 ODM memo Trading Partners and Select Medicaid Provider Organizations with billing providers and stakeholders.

Does credentialling with ODM mean I participate with the health plan?

No, you still need to join the Buckeye Health Plan to be a participating provider with Buckeye. 

What is the payor id for electronic submission for Medicaid?

For dates of service 2/1/23 and forward the payor ID is 0004202

What is the behavioral health payor ID?  

For dates of service 2/1/23 and forward the payor id is 0004202

What is the Timely Filing to submit a New Claim with the New Contract?

For dates of service 2/1/23 and forward 365 days from the DOS

What is the Timely Filing to submit an Appeal with the New Contract?

Effective 2/1/23 Dispute is 12 months from date of service or 60 days from EOP date whichever is later.

What is the time frame to submit a corrected claim with the new contract?

For dates of service 2/1/23 and forward corrected claims is 365 from DOS

What is the turnaround time for Buckeye to process a New claim? 

For dates of service 2/1/23 and forward, turnaround time is 21 days

What is the turnaround time for Buckeye to process a corrected claim? 

For dates of service 2/1/23 and forward, turnaround time is 21 days

A message from ODM:

Claim submission and adjudication reminders

With the launch of the new Electronic Data Interchange (EDI) along with the Fiscal Intermediary (FI) as part of the Next Generation of Ohio Medicaid program on February 1, the EDI became the new exchange point for trading partners on all claims-related activities, providing transparency and visibility regarding care and services. The FI, in conjunction, now assists in routing managed care claims submitted to the EDI and adjudicates and pays fee-for-service (FFS) claims submitted to the EDI.  

We understand this transition has adjusted how you submit and access claims. Please refer to the guidance below for direction and reminders on the claim submission process. 

Where do you submit claims?

For providers who utilize direct data entry (DDE)

• FFS claims submitted using DDE continue to be submitted from a Medicaid Information Technology System (MITS) portal page accessed via a link in the Provider Network Management (PNM) module. FFS claims submitted through the PNM module continue to be paid by OAKS, the State of Ohio’s accounting system. 
• Managed care claims submitted using DDE should be processed through the applicable managed care entity (MCE) portal. 

For providers who utilize a trading partner

• All managed care and FFS claims submitted by trading partners are submitted through the new EDI. Providers with a trading partner should confirm their trading partner has completed all required connectivity activities with Deloitte, the new EDI vendor. 
• FFS claims submitted by a trading partner through the EDI are sent to the Fiscal Intermediary (Gainwell Technologies) on behalf of ODM for processing and payment. 

Where do you submit claim attachments?

• All managed care attachments are handled by the applicable MCE. Providers should work with each MCE to submit attachments following the process outlined by that MCE.  
• FFS claim attachments are submitted from a MITS portal page accessed via a link in the PNM module. Trading partners do not submit attachments on behalf of providers. 

Where do you edit claims?

Edits to claims, including adjustments and voids, are submitted utilizing the same method (MCE portal, MITS page accessed via the PNM module, or through a trading partner utilizing the new EDI) as the original claim submission. 

Where do you go for more information on claims?

For claims submitted but not yet paid:

• If a trading partner submitted the claim through the new EDI and the claim was passed to the MCE, including claims sent from Ohio Department of Medicaid (ODM) to the MCE for adjudication, the provider should visit the applicable MCE’s portal. 
• FFS claims submitted but not yet paid are not visible to providers. These claims will not be visible in the PNM module until a future system release.

For paid claims:

• All payers' .pdf remittance advices (RA) are available to providers on the PNM portal. This includes MITS, FI, and MCO RAs. 
• If a provider is enrolled with ODM to receive an 835, that enrollment applies to both FFS and MCO activity. 835s from all payers are delivered by the trading partner. 

Authorized Trading Partners are able to submit the 276 Claim Status transaction for more detailed information upon the receipt of the 277 Claim Acknowledgment (277CA).

Additional information on claim submission for providers who utilize trading partners

With the launch of the new EDI, changes in the claim submission process are required for trading partners to exchange transactions in the new EDI. Providers should work with their trading partners to determine the changes that may be needed to their systems and staff training. A few important changes for providers who utilize trading partners to note are as follows: 

• 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. 
• Provider claims submitted to trading partners must include the Medicaid member ID (MMIS). 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. 
• Each managed care claim must include the internal managed care payer ID and a receiver ID. FFS claims also require a payer and receiver ID but they remain the same. If you submit your own claims through the EDI, please refer to the ODM Companion Guides for the updated receiver and payer IDs list. 

Do you have questions?

Information is available on the submitting claims and prior authorizations page on the Next Generation website. For additional help contact the Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. Special hours from 7 a.m.-7 p.m. will conclude after today February 24, and regular hours of 8 a.m.-4:30 p.m. Monday-Friday will resume. 

Next Generation February 1 Launch Provider Webinar

January 19 – 3:00 to 4 Eastern

Register Here

ODM is continuing its provider awareness and training efforts in preparation for the February 1 launch of the Next Generation program!

Hosting a 1-hour webinar to share information on the exciting changes Ohio Medicaid providers can expect, including an overview of the transition to the Next Generation managed care plans, Electronic Data Interchange, and Fiscal Intermediary. Additionally, we will discuss key changes and where resources are available to assist providers in the transition.

If unable to attend, the webinar will also be made available as a recording on the Resources for Providers webpage of the Ohio Medicaid Next Generation website.

Provider Network Management (PNM) Refresher Training

• Agent setup and assignment.
• Adding/editing/confirming affiliations.
• Completing an update.
• Explanation of why enrollment actions do not display.
• Explanation of current statuses in the PNM module.
• Medicaid Information Technology Systems (MITS) redirection/issues. 
  • PNM helpful tips.
  • Accessing remittance advice.

PNM Refresher Training Schedule: Sign-Up

The Learning Management System (LMS) is where the self-paced and virtual training sessions are accessed.

If you do not have an account in the LMS, it’s important that you create one to ensure you can access all training sessions, answer forms, and view a variety of Provider Network Management (PNM) module resources. Access the job aid and follow the steps to create your account and register for training.

Ohio Department of Medicaid (ODM) Fiscal Intermediary (FI) end-user refresher training began January 9. This is open to all ODM and sister state agency staff, recommended for those who will directly access the FI to perform administrative functions. This training mirrors the content delivered during the first round of FI end-user training, which occurred October 24-November 18, 2022.

FI refresher courses will be conducted live via Gainwell’s learning management system (LMS). If you have not yet registered as a user in the LMS please go to Access our LMS, select the Sign-In button and the Enrollment Key Screen will open. Enter PkCGZGpevLODtmrsZItq for the enrollment key. Please ensure there are no extra spaces before or after the enrollment key.  

• If you have a non-FI, Gainwell LMS account, you still need to create a new account using a different username. An example of a non-FI account is Ohio Gainwell Single Pharmacy Benefit Manager (SPBM).

January 10-17 courses

Refresher training started this week, which includes multiple session options for the VUE360 refresher courses. Please note there will not be a general navigation/introduction overview of VUE360 in these courses. If you would like a summary of VUE360, you can complete the “OH – VUE360 – Overview (eLearning)” online course in the LMS at your own pace.  

Courses

Registering in the learning management system

Each course is a separate registration in the LMS and represents a Tile/Topic in VUE360. This provides the trainee with flexible options to attend each session. 

Multiple sessions have been added for the “VUE360 Overview” courses to assist with schedule accommodations. Each course has two session options, but you only need to enroll in one. After searching for the desired course, click “Choose Session.” 

Select the session you wish to attend in the LMS on the Course Content page of the training by clicking “Enroll.” See the example below:  

Question and answer sessions

The FI is also offering question and answer (Q&A) sessions for those who are seeking further clarification on the following topics:

The Q&A sessions are open to anyone who has questions related to the topic.  

If you have questions regarding registering in the LMS or enrolling in any of the courses, please contact LMS administrator Brandon Valentine via email at Bvalentine4@gainwelltechnologies.com. If Brandon is unavailable, please send any requests to baselinemedicaidtraining@gainwelltechnologies.com.  

February 1 Launch of Next Generation of Ohio Medicaid

Over the past year, Ohio Department of Medicaid (ODM) has prepared for and successfully launched many components of the Next Generation Ohio Medicaid program. Our implementation has consistently followed two of our key Next Generation commitments – to focus on the individual and improve the provider experience. ODM remains committed to listening to members, providers, and managed care plan partners, and we have taken a hands-on approach to resolving implementation issues that providers have experienced.  

Based on your feedback, ODM updated its launch timeline to ensure a smooth transition. So, on February 1, our seven Next Generation managed care plans will begin serving members with an increased emphasis on personalized care. At the same time, ODM's new Electronic Data Interchange (EDI) and the Fiscal Intermediary (FI) will go live. 

What can providers expect on February 1?

Of the February 1 launch, the new EDI and FI will impact providers the most. As we phase in these new system components, some of your day-to-day processes will change while some will remain the same. Read on to understand how you will be affected. 

Claims and prior authorization (PA) submitted through trading partner

• 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 to the PNM module. 
• 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.  
• 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. ​ 

How to stay informed

ODM will continue to use the ODM Press to provide information about the upcoming implementation for providers. In the meantime, please reach out to the Next Generation mailbox with questions. Thank you for your continued partnership and support of the Next Generation Ohio Medicaid program! 

Over the past year, Ohio Department of Medicaid (ODM) has prepared for and successfully launched many components of the next Generation Ohio Medicaid program. ODM’s implementation has consistently followed two key Next Generation commitments – to focus on the individual and improve the provider experience. ODM remains committed to listening to members, providers, and managed care plan partners, and taking a hands-on approach to resolving implementation issues that have been experienced by providers. ​Leading up to our next implementation, ODM has been actively seeking input from stakeholders and conducting testing of all systems.

What does this mean for providers?

Based on the feedback ODM has received and their commitment to careful transitioning, ODM did not implement the new Next Generation managed care plans and the full Ohio Medicaid Enterprise System (OMES) launch on December 1. The new lineup for implementation is as follows:

• On February 1, 2023, ODM will launch the Next Generation managed care plans and program requirements, including exciting improvements that will support members in accessing the healthcare services and supports they need. ODM will also implement the new Electronic Data Interchange (EDI), increasing transparency and visibility of member care and services.
• Subsequently, ODM will fully launch OMES modules to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers.

Providers should continue conducting business as they do today on and after December 1 – including the processes, procedures, and systems used today to submit claims, submit prior authorizations, and complete other administrative functions. Providers can submit their direct data entry managed care claims and prior authorizations to the Buckeye Portal Login found on our Provider Home Page.

ODM will provide more information about the upcoming implementation for providers in the coming weeks. To receive updates from Ohio Medicaid, please subscribe to the ODM 2022 Press. You may also contact Buckeye Provider Services by calling 866.296.8731.

Thank you for your continued partnership and support of the Next Generation Ohio Medicaid program!

Behavioral Health Provider Network Management (PNM) Refresher Training now open for registration! 

A PNM virtual refresher training is available for behavioral health providers, scheduled
for Wednesday, December 14, 1-3 p.m. Eastern time (ET).  

Training module topics will include the following: 

• Eligibility Rule & Guideline Reminders. 
• Workflows. 
• Changing Provider Types and/or Adding Specialties. 
• Initiating a New Provider Application. 
• Completing Updates. 
• Who to Contact to Resolve Issues? 

Learning Management System registration

Absorb, the Learning Management System (LMS), is where you will sign up for this virtual session. If you do not have an account in the LMS, it’s important that you create one to ensure you have access to all training sessions, answer forms, and a variety of PNM resources. Access the Job Aid and follow the steps to create your account and register for training. 

For more information

To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. If you are experiencing any technical issues accessing the PNM module or have specific questions, please contact Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. The IHD is open Monday-Friday, 8 a.m.-4:30 p.m. ET. 

A message from ODM:

Over the past year, Ohio Department of Medicaid (ODM) has prepared for and successfully launched many components of the Next Generation Ohio Medicaid program. Our  implementation has consistently followed two of our key Next Generation commitments – to focus on the individual and improve the provider experience. To meet these commitments, on July 1, ODM implemented OhioRISE (Resilience through Integrated Systems and Excellence) and on October 1, we implemented the Single Pharmacy Benefit Manager (SPBM) and Centralized Credentialing for providers. The feedback has been clear about the significant benefits members and providers have experienced because of these new program changes.

Our focus has been and continues to be on implementing new components and improvements as they are fully ready to support achieving our mission. ODM remains committed to listening to members, providers and managed care plan partners, and we have taken a hands-on approach to resolving implementation issues that have been experienced by providers. ​Leading up to our next implementation, we have been actively seeking input from stakeholders and conducting testing of all systems.

What does this mean for providers?

Based on the feedback we have received and our commitment to carefully transitioning, we will not implement the new Next Generation managed care plans and the full Ohio Medicaid Enterprise System (OMES) launch on December 1. The new lineup for implementation is as follows:

• On February 1, 2023, ODM will launch the Next Generation managed care plans and program requirements, including exciting improvements that will support members in accessing the healthcare services and supports they need. ODM will also implement the new Electronic Data Interchange (EDI), increasing transparency and visibility of member care and services.
• Subsequently, ODM will fully launch OMES modules to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers.

Providers should continue conducting business as you do today on and after December 1 – including the processes, procedures and systems used today to submit claims, prior authorizations and complete other administrative functions. ODM will provide more information about the upcoming implementation for members and providers in the coming weeks.

Thank you for your continued partnership and support of the Next Generation Ohio Medicaid program!

Please reach out to the Next Generation mailbox with questions. Thank you for your continued partnership and support of the Next Generation Ohio Medicaid program!

What is a Provider Journey Map?

The Provider Journey Maps are process maps that visually illustrate various activities required for providers to perform as part of their participation with the Next Generation of Medicaid Program. The Provider Journey Maps detail common provider activities, explaining the main activities performed by providers starting on December 1. We encourage providers to review the Provider Journey Maps to understand from a high-level, how common activities will be performed, and how providers can prepare in advance for these activities. Please see below for the comprehensive list of Provider Journey Maps.

December 1 – Stage 3 Provider Journey Maps

• PNM Module Functions
• Integrated Help Desk (IHD)
• Member Eligibility Verification
• Prior Authorization Submission
• Claims Submission

New Trainings for 12-1-22 Launch Date

In preparation for the Phase 3 launch on 12-1-22, ODM has scheduled new trainings on how providers can use the Provider Network Management module (PNM)  to bill claims and get prior authorizations as of 12/1. Be sure to learn more details and sign up at ODM Training and Resources. 

Next Generation of Ohio Medicaid Program Has Launched - What you need to know!

On October 1, the Ohio Department of Medicaid (ODM) launched Centralized Credentialing in the Provider Network Management (PNM) module and Single Pharmacy Benefit Manager (SPBM) as part of the Next Generation of Ohio Medicaid program. Through this launch, ODM has helped reduce administrative burden on providers.  

The Next Generation managed care program 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. 

What can providers expect with the launch of the SPBM?

• Pharmacists and prescribers have a greater ability to monitor quality, transparency, and accountability in the pharmacy program.    
• The SPBM implements a single set of clinical/prior authorization policies and claims process, and serve as a single point of contact, reducing the administrative burden on providers. 
• All managed care members have new Medicaid ID cards. If a member presents an old Medicaid ID card, use the Gainwell RxBIN (024251), Gainwell RxPCN (OHRXPROD), and 12-digit Ohio Medicaid Member ID (formerly MMIS ID).

What can providers expect with the launch of Centralized Credentialing and PNM?

• Providers subject to credentialing can be credentialed just once at the state level versus a separate credentialing process for each Ohio Medicaid managed care plan. 
• There is no longer a need for paper agreements at long-term care facilities – all agreements are available online and do not require mailing back and forth for signatures. 
• Providers now can view specialties and effective dates.

Ohio Medicaid has hosted a variety of provider webinars and trainings. If you missed the Next Generation of Ohio Medicaid Program Provider Overview Webinar, which reviewed the transition to the Ohio Medicaid Enterprise System (OMES) modules – including the SPBM and PNM – review the recording here. If you were unable to attend or haven’t yet viewed the trainings available for PNM or SPBM, you can find training modules, recordings, and more by visiting the Provider Webinars and Trainings webpage of the Next Generation website.

Help desks are available. If you have questions related to pharmacy claims, prior authorizations, and other administrative tasks, contact the Gainwell SPBM Help Desk at (833) 491-0344 or visit https://spbm.medicaid.ohio.gov. Questions related to Centralized Credentialing and the PNM module, OH|ID, and portal password support should be directed to the ODM Integrated Help Desk at (800) 686-1516. For resources related to PNM and Centralized Credentialing, visit the PNM and Centralized Credentialing webpage on managedcare.medicaid.ohio.gov. For resources related to OH|ID, visit the OH|ID Help webpage.

Learn more about the changes coming with the October 1 launch of the Next Generation program and their benefits for you! The SPBM reduces  administrative burden by allowing you to work with only one PBM and by providing access to the SPBM portal where you can check eligibility of Ohio Medicaid members, submit and view prior authorizations and claims, and more. 

The PNM allows providers to submit a single Ohio Medicaid enrollment and credentialing application. Providers will still contract separately with Ohio Medicaid MCOs. The PNM provides a single entry-point for enrollment, revalidations, and credentialing, and more. 

Learn more by reading the SPBM FAQs document and PNM FAQs document. You can also visit the Resources for Providers webpage of the Next Generation website to access information about the October 1 improvements and changes.

Do you have your OH|ID?

Be ready for changes coming to Medicaid beginning October 1.

Beginning October 1, all Buckeye Health Plan Medicaid providers will need an  OH|ID, the State of Ohio’s digital identity standard, to access Medicaid’s new Provider Network Management (PNM) module and the single pharmacy benefit manager (SPBM) secure web portal.

If you missed the September 23 PNM preregistration deadline, you can still get your OH|ID – the first step to securely access Medicaid enterprise systems.

Why this is important:

The OH|ID is required to securely access state agency systems. It gives providers a single set of logon credentials to securely access state agency systems, including Medicaid’s, from any device. The ID adheres to best practice security and privacy regulations as defined by the National Institute of Standards and Technology (NIST). Agencies and users using the OH|ID can rest assured that their digital identities are kept safe and secure. The OH|ID

Get your State of Ohio digital identification - the OH|ID today.

Beginning October 1:

Anyone accessing the PNM or the SPBM secure web portal when they go live on October 1 will need an OH|ID to log in and complete key administrative tasks and processes. The following resources are available to providers to assist in setting up an account.

• Create an OH|ID account.
• Get help logging in.
• View an in-depth OH|ID account creation user guide.

Providers needing technical assistance should contact the Ohio Department of Medicaid Integrated Help Desk (IHD) at 800.686.1516. Hours of operation are Monday-Friday, 8 a.m. - 4:30 p.m. ET.

Are you ready for changes coming to Ohio Medicaid on October 1?

To submit claims and prior authorizations or update enrollments as of October 1, you’ll need to preregister with your OH|ID for the Provider Network Management (PNM) module by September 23.

In July, ODM hosted a webinar for providers on the Next Generation's Stage 2 October 1 launch. This webinar included an overview of the new modules and upcoming provider training plans and dates. Please see below for a recording of the session and the corresponding slides.

• Next Generation Ohio Medicaid Program Provider Overview Slides
• Next Generation Ohio Medicaid Program Provider Overview Recording

You can also check out the PNM & Centralized Credentialing and Single Pharmacy Benefit Manager (SPBM) webpages. For questions about the Next Generation program, contact ODMNextGen@medicaid.ohio.gov.

We are excited to announce that the PNM Pre-Registration tool is live! As a reminder, the Ohio Department of Medicaid (ODM), Department of Developmental Disabilities (DODD), and the Ohio Department of Aging (ODA) are implementing a new Provider Network Management (PNM) module on October 1, 2022. The PNM module will replace the current MITS provider enrollment subsystem and MITS provider portal and will require an OH|ID for provider access. The PNM Pre-Registration tool will be available from August 15 until September 23 and will ease the transition and prevent disruptions to system access for providers ahead of go-live on October 1, 2022.

How do I access the PNM Pre-Registration tool?

Please visit PNM Pre-Registration tool directly to access the tool directly. You can also access the PNM pre-registration tool through a link on the PNM & Centralized Credentialing page. From there, you will be able to begin the pre-registration process. For providers who have already created an OH|ID, the pre-registration process will only take a few minutes as you will simply connect your existing account to the PNM module.

What should I do if I don’t have an OH|ID yet?

The PNM Pre-Registration tool will automatically redirect you to the OH|ID account creation site, but you can also create an OH|ID in just a few minutes using the steps below:

1. Go to OH|ID Login.
2. Fill in the appropriate fields with user information and create account.
3. An email confirmation will be sent following registration.
4. Once you have logged in, please fill in the required fields with the correct security information and address any error messages that appear if you complete the security questions unsuccessfully.

Need Help?

To learn more about the PNM module and Centralized Credentialing, visit the PNM & Centralized Credentialing site. If you have questions about OH|ID, please visit the OH|ID Help Center (Please note: OH|ID account log in is required to access this site.)

Provider Enrollment and Maintenance Update

Beginning Aug. 1, the Ohio Department of Medicaid (ODM) will temporarily stop accepting provider enrollment applications as we transition to the new Provider Network Management (PNM) module. New providers should enroll by July 31 or plan to hold enrollment applications until Oct. 1. Information about OhioRISE provider enrollment during this time is forthcoming.

If you are a provider who is not currently enrolled and wish to enroll to provide any services under the Next Generation of Ohio Medicaid, please visit the link to the Ohio Medicaid online application by July 31: 

Beginning Aug. 31, all provider demographic and agent maintenance update functionality will be closed for conversion of data in MITS. Enrolled providers should update their demographic information in MITS by Aug. 30 or plan to hold updates until Oct. 1. Please visit the link to the MITS Secure Portal Login.

Please make sure to add or update all practice locations and provider affiliations in advance of data conversion.

On Oct. 1, provider enrollment and maintenance-related activities will resume and be accessed using PNM. For more information visit PNM and trainings.

Registration is open for Provider Network Management (PNM) Training!

As you are likely aware, Ohio Medicaid is in the process of implementing our Next Generation program to focus on the individual rather than the business of managed care so that we can do better for the people we serve. One way we hope to achieve this vision is through the implementation of the Provider Network Management (PNM) module to reduce the administrative burden on providers.

Training and Learning Management System

In preparation for Stage 2 go-live (Oct. 1, 2022), we are offering a variety of training options including self-paced, virtual, and in-person training options. Absorb, the Learning Management System (LMS), is where you will access the self-paced training and sign up for the virtual and/or in-person sessions.

LMS Registration

Training sessions are scheduled to begin Aug. 1, 2022, and it is important that you create an account in the LMS to ensure you have access to all training sessions, answer forms, and PNM resources in advance. Click on the appropriate link below, based on your provider type, to access the LMS and follow the steps to create your account and register for training:

Questions

Please email ohiotrainingteam@maximus.com with any questions regarding training sessions or additional information.

About the PNM and Centralized Credentialing

The PNM module and Centralized Credentialing program are part of the “Big 5” strategic initiatives being implemented within the Next Generation of Ohio Medicaid’s managed care program.

The PNM will replace the current Medicaid Information Technology System (MITS) provider enrollment subsystem provider portal. This module will be implemented along with Centralized Credentialing, which is a state-level single centralized provider credentialing process. These initiatives will modernize the system by streamlining processes and reducing administrative burdens for providers. For more information about PNM and Centralized Credentialing, visit the Managed Care website.

In preparation for the October 1, 2022, Stage 2 launch of the Next Generation program, the Ohio Department of Medicaid (ODM) is kicking-off its provider awareness and training efforts.

They are hosting 2-hour webinars, customized by provider type, to share information on the exciting changes. Providers can expect, an overview on the transition to the Ohio Medicaid Enterprise System (OMES) modules, upcoming training plans and dates, and how providers can receive communications from ODM throughout the Next Generation transition and implementation.

Please utilize the links below to register for the provider group session that you best fit. We kindly request that providers only join one live event due to capacity limitations.

The webinar is being offered several times and will also be made available as a recording on Resources for Providers webpage of the Ohio Medicaid Next Generation website.

So using the first one as an example, something like "Register for the Physicians, Physician Groups, Podiatrists webinar" would work, or "Register for the webinar on Tuesday, July 19th 3:00pm – 5:00pm ET"

Physicians, Physician Groups, Podiatrists
Register for the webinar on Tuesday, July 19th 3:00pm – 5:00pm ET

Behavioral Health Organizations and Individual BH Practitioners
Register for the webinar on Wednesday, July 20th 1:00pm –3:00pm ET

Hospitals, Ambulatory Surgical Centers, Pharmacies 
Register for the webinar on Thursday, July 21st 9:00am – 11:00am ET

DODD, ODA, ODM HCBS Waiver Providers (Independent Providers and Agencies, Assisted Living Providers) 
Register for the webinar on Friday, July 22nd 10:00am – 12:00pm ET

Physicians Assistants, Advanced Practice Nurses, Occupational Therapists, Physical Therapists, Dietitians, Audiologists, Speech Language Therapists, Medicaid School Program 

Register for the webinar on Monday, July 25th 3:00pm –5:00pm ET

Rural Health, Community Health Centers, General Public Health, FQHC 
Register for the webinar on Tuesday, July 26th 9:00am – 11:00am ET

Dentists, Optometrists, Chiropractors (Non-Physician), DPM Professional Degrees) 
Register for the webinar on Wednesday, July 27th 1:00pm –3:00pm ET

Long Term Care Facilities (SNF and ICF-IID), Home Health Agencies, Hospice 
Register for the webinar on Thursday, July 28th 3:00pm – 5:00pm ET

DME Providers, Transportation Providers, Other Providers 
Register for the webinar on Friday, July 29th 10:00am – 12:00pm ET

The Ohio Department of Medicaid (ODM) will begin to launch its Next Generation Medicaid program beginning July 1, 2022, with the implementation of OhioRISE, a coordinated care program for children with complex behavioral health needs. Other Medicaid programs will be implemented in the following months on a staggered basis to keep the focus on the individual and honor member choice to allow for a smooth transition.  

This staggered start ensures continuity of care, limits confusion, and reduces complexities surrounding the anticipated end of the federal public health emergency (PHE) and provides the necessary time for provider testing and training.  

The phased implementation will occur in three stages: 

Stage 1: On July 1, OhioRISE will begin to provide coordination and specialized services to help children and youth with behavioral health needs who receive care across multiple systems. 

Stage 2: In October 2022, Centralized Provider Credentialing will begin through the Ohio Medicaid Enterprise System (OMES) Provider Network Management (PNM) module, which will reduce administrative burden on providers. Also, the Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members.

Stage 3: During the last three months of 2022, ODM will finish implementing the Next Generation program with all seven Next Generation managed care plans beginning to provide healthcare coverage under the new program. ODM will also complete the OMES implementation including the Fiscal Intermediary (FI) which will simplify and streamline the provider process for submitting claims and prior authorizations.

Ohio Medicaid is committed to launching the Next Generation Medicaid correctly. The phased timeline assures no disruption to members’ care or provider support.

For full details of ODM's announcement, visit Ohio Medicaid’s Next Generation program to launch July 1 with OhioRISE | Medicaid

The Ohio Department of Medicaid (ODM) along with the Department of Developmental Disabilities (DODD) and Ohio Department of Aging (ODA) are in the process of implementing a new Provider Network Management (PNM) module and Centralized Credentialing effective July 1, 2022.

In preparation for the rollout of the new system, ODM is expected to implement a freeze period some time in May. During the freeze, ODM will not process or update information on the MITS system as they migrate current information over to the new PNM file.

Once the migration is complete, all Managed Care Plans will be expected to mirror the information in the PNM file. Files will be shared and loaded onto the Buckeye Health Plan system to reflect only the information that is on file through the State of Ohio.

We are asking all providers to update their information on the Provider Master File (PMF) through MITS prior to the anticipated freeze. MITS Provider Directory

For more details regarding the new PNM and centralized credentialing please visit the website link PNM & Centralized Credentialing | Ohio Medicaid Managed Care.

Thank you in advance for taking the time to update all your demographic information.

Slides for Providers Submitting PA and Attachments for MCE's via PNM Portal - Coming Soon