EDI: Electronic Data Interchange

From ODM: “Ohio Department of Medicaid (ODM) is in the process of modernizing its management information systems. This modernization roadmap was developed in accordance with Centers for Medicare and Medicaid Services (CMS) guidance and includes a transition to a modular system called the Ohio Medicaid Enterprise System (OMES) that will support ODM in meeting several modernization goals.”    

“Managed care claims submitted via the EDI will be routed to the MCOs for processing, adjudication, and payment. Please note, these changes do not apply to MyCare. MyCare providers should continue to submit claims and prior authorizations directly to the appropriate payer, either the MyCare managed care plan or Medicare. “

Per the information provided by ODM, all MCOs have been instructed to reject claims received for Medicaid members for DOS on or after 2/1/23 that were received by the MCO and not sent through the OMES Fiscal Intermediary.  This rejection will display as the following:

• D1 - DOS on or after 2/1/23, submit to OH Medicaid Intermediary

In addition, any MyCare claims received through the OMES Fiscal Intermediary will be rejected to instruct the provider to re-submit using Buckeye’s payor ID(s).  This rejection will display as the following:

• D6 - Submit All MyCare Claims to Payer Id 68069 or 68068

For additional information reach out to ODM.

Dispute Bullets

• The new provider claim dispute process applies to the Medicaid line of business only and are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim denial. Disputes include claims requiring Medical Necessity/Level of Care Review but, do not include inquiries that come through ODM’s Provider Web Portal (HealthTrak).
• In order to submit a claim dispute, there must have been a previously submitted claim that has either paid or denied and the provider disagrees with the prior outcome.
• Please ensure provider claim disputes contain any additional or required documentation and clearly define the providers expectations/request in order to ensure accurate review is completed.
  • Disputes related to Medical Necessity/Level of Care require the Medical Necessity / Level of Care (LOC) Claim Dispute Form.
• Providers are allowed 12 months from date of service or 60 calendar days after the last payment, denial, or partial denial of a timely claim submission, whichever is later.
• The Provider Web Portal can be utilized to submit a claim dispute as well as track the status of the claim dispute. Submitting the dispute through the portal is the most direct submission method and allows for faster review times.
• The provider may also reach out to Buckeye Health Plans Provider Services to check the status of the dispute at 1-866-296-8731, Monday – Friday 7 a.m. to 8 p.m. (EST)
• Please refer to Buckeye Health Plans Medicaid Provider Manual for additional information on and how to submit a dispute per the updated dispute guidelines.

The Ohio Department of Medicaid (ODM) is providing additional clarification relevant to EDI-related claims submissions on February 1 and later concerning rendering providers. ODM will require one rendering provider per claim at the header level, rather than the detail level, for professional claims for both fee-for-service (FFS) and managed care recipients 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.

As part of the Next Generation of Ohio Medicaid program, we are taking a hands-on approach to resolving Electronic Data Interchange (EDI) implementation issues that trading partners have experienced. 

As we move into Certification Testing (CERT) and are preparing for production, the level of security required to interact with these systems is increasing. Trading partners leveraging the EDI Trading Partner Management Application will be required to:

• Obtain a State of Ohio ID (OH|ID)
• Establish Multi-Factor Authentication (MFA) via the State’s InnovateOhio Platform (IOP).

The additional security aims to improve user connectivity and to prevent hacking and the inadvertent exposure of sensitive data. To keep information secure, the EDI trading partner management application can only be accessed by logging in with OH|ID credentials and successfully completing the MFA setup. The MFA process is well documented, and many providers already use it in production within other state systems.

Please complete the following steps:

1. As soon as possible, but no later than Thursday, January 12: Review the attached OH|ID/MFA guide and the complete the steps within.
2. After successfully completing the OH|ID and MFA setup activities: Review the trading partner management application user guide and the functionalities offered in the tool.

Thank you for your participation so far. We especially appreciate your willingness to help us test and troubleshoot new parts of the Ohio Medicaid Enterprise System (OMES).

If you have any questions or feedback, please do not hesitate to reach out to usomesedisupport@deloitte.com.