We are proud to partner with the Ohio Department of Medicaid (ODM) through its Next Generation Medicaid program to help improve wellness and health outcomes for Medicaid recipients in Ohio. We include below important information for all Ohio Medicaid providers.
IMPORTANT: ODM WILL NOT YET DENY CLAIM DENIALS ASSOCIATED WITH DATA INTEGRATION TO ENSURE READINESS
Continue to make your PNM updates Ohio Department of Medicaid (ODM) met with key stakeholder associations and their members (regarding ODM’s direction to deny claims due to data misalignment between the managed care entities’ (MCE) systems and Ohio Medicaid’s Provider Network Management (PNM) system generated Provider Master File beginning on October 20. As a result of the feedback and discussion, ODM has determined that MCEs will not be denying claims for PNM System data misalignment at this time. ODM will continue to work with the MCEs to determine a date in the future to initiate this process.
ONGOING ACTION REQUIRED: Providers or trading partners.
It is essential that providers continue to update their data in the PNM Module so that the validation testing being done with the plans will be successful. ODM will be moving this change into production and all the work to keep the PNM up to date will ensure there will be minimal impact when it is rolled out.
Exciting changes to Ohio’s Medicaid program as of Feb. 1, 2023
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
Key changes effective Feb. 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 did not change on Feb. 1
FFS prior authorizations will continue to be submitted through the PNM module link to MITS.
Managed care prior authorizations will continue to be submitted to each plan using their existing processes.
The new EDI will not accept prior authorizations of any kind.
Portal submitted claims and all prior authorizations
Key changes effective Feb. 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 did not change on Feb. 1
Continue using managed care plan portals to direct data enter claims and prior authorizations.
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 prior authorization 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 Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.
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 800-868-1516 or IHD@medicaid.ohio.gov.
For billing and prior authorization guidance, call us at 877-856-5707, Monday – Friday, from 7 a.m. – 8 p.m., Eastern time.
Humana Healthy Horizons has served Medicaid populations continuously for more than 2 decades and currently manages Medicaid benefits for nearly 800,000 members nationally. We developed expertise providing care management, care planning, and specialized clinical management for the complex needs of members within a social supports‐based framework.
We also developed significant expertise in integrating physical health, behavioral health, pharmacy and social services and supports for a whole-person centered approach to improve the health and well‐being of our members and the communities we serve.
In Ohio, Humana already serves 568,000 residents through Medicare Advantage, Medicare prescription drug plans, commercial employer-sponsored plans, commercial dental and vision coverage, and TRICARE.
For more than two decades, Humana has served Medicaid populations and currently manages Medicaid benefits for nearly 800,000 enrollees nationwide. Humana Healthy Horizons is committed to continue demonstrating our ability to manage complex populations and create solutions that lead to a better quality of life for our members.
We are pleased to announce that Humana Healthy Horizons in Ohio is launching in early 2022. In partnership with the Ohio Department of Medicaid, we will work with our provider network to serve our members in Ohio, and help them reach their health goals and get the right care in the right place at the right time.
Helping keep our members in their best health is what human care is all about.
Join our network
By working closely with our providers, we can help our members in Ohio:
Develop strong relationships with their primary care provider
Get the right care in the right place at the right time
Set and reach health goals
Once ODM completes implementation of its Next Generation Medicaid program, Humana Healthy Horizons in Ohio will administer care focused on Temporary Assistance for Needy Families, Expansion, and Assisted, Blind, and Disabled populations in the west, northeast, and central/southeast regions.
For additional information about joining our network: