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Central Region
August 2, 2023
August 2023 Managed Care Plan Updates

This past month, the managed care plans have published updates on events and policy changes impacting their organizations.

AmeriHealth Caritas Updates: 

  • Defects impacting delivery of 835 files: Ohio Department of Medicaid (ODM) is aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch on February 1. ODM understands the importance of timely and accurate data exchange and is committed to ensuring a smooth and reliable user experience. Over the last few months, ODM and its vendors have been identifying and correcting 835-related errors. As a result of the fixes, the majority of missing 835 details have been generated. A large batch was released on May 24, followed by a second batch released on June 26, and another on July 7. Click here to read more about this issue.
  • Billing evaluation and management services with behavioral health evaluation codes: In an effort to reduce administrative burden and expand access to behavioral health services, AmeriHealth Caritas will reimburse claims for evaluation and management services and behavioral health evaluations, when the level of care warrants the usage of the behavioral health evaluation and documentation supports that these services are separately identifiable, in accordance to Ohio Administrative code 5160-27.03 and Appendix A, 5160-27-03. Click here to read more about this update and billing.

CareSource Update:

  • UPDATE – Rejection of Claims that Bypass the ODM Fiscal Intermediary: CareSource is updating the reject code from 585 “Denied Charge or Non-Covered Charge” to reject code – 506 “Entity is changing processor/clearinghouse”. As of June 27, 2023, this claim must be submitted to the new processor/clearinghouse. For more information, please visit ODM’s website and read the full CareSource update here.

Molina Updates: 

  • Ohio Amblyope Registry: Providers can register any patient, up to 18 years of age, who has been diagnosed with lazy eye (amblyopia) with the Ohio Amblyope Registry (OAR) program for free. Registration makes the patient eligible for resources to help with treatment, including educational material about amblyopia, children’s storybooks about lazy eye, and free eye patches for patching therapy. To learn more about the Amblyope Registry, visit OhioAmblyopeRegistry.com or call (877) 808-2422. Click here to read the update in full.
  • Behavioral Health QMHS Billing Modifier: Molina posted a reminder that Behavioral Health providers with a Qualified Mental Health Specialty
    (QMHS) should be billing the appropriate modifier for the level of licensure as shown below. Claims could deny if the appropriate specialty and modifier is not billed accurately and updated in ODM’s PNM system.
    – High School (QMHS): Practitioner Modifier HM
    – Associate’s (QMHS): Practitioner Modifier HM
    – Bachelor’s (QMHS): Practitioner Modifier HN
    – Master’s (QMHS): Practitioner Modifier HO
    – 3 Years’ Experience (QMHS): Practitioner Modifier UK
  • Updated: Medicaid Enrollment Requirements: As a reminder, any provider, group, ordering, or referring who is not enrolled and noted as “active” in the ODM Provider Network Management (PNM) system will receive denials for claims submitted to Molina. Claim denials will continue until the provider’s Medicaid enrollment is noted as an “active” status. Click here and scroll to the top of page 4 to learn more.
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