This past month, the managed care plans have published updates on events and policy changes impacting their organizations.
- Next Generation of Ohio Medicaid Managed Care: Payer ID Change – UPDATE: In alignment with the Next Generation Managed Care Initiative, CareSource is required to change their Payer ID. The CareSource Payer ID is changing from 31114 to 0003150 for Ohio Medicaid providers only. The new Electronic Data Interchange (EDI) will be implemented on Feb. 1, 2023 for claims only. The new EDI will not accept Prior Authorizations (PA) until Stage 3b is implemented. The Provider Network Management (PNM Portal) will not accept claims or PAs until Stage 3b is implemented by Ohio Department of Medicaid (ODM). Providers must reflect the CareSource Payer ID change when submitting claims with a Date of Service on or after Feb. 1, 2023. The Date of Service to input the new CareSource Payer ID for submitting PAs through the new EDI and submitting claims and PAs through the PNM Portal will be defined by ODM. Click here to read the update in detail.
- New Molina Medicaid Payer IDs: Effective February 1, 2023, new Molina payer IDs must be used for the ODM OMES EDI transaction. The payor id are pictured below. Click here to read the full update for Next Generation Medicaid activity taking place at Molina.
- Update to Claim Dispute Process: Effective February 1, 2023, Molina Provider Services will no longer accept claim disputes via email. All claim disputes for a denial, payment amount, or code edit must be submitted following the Claim Dispute Process. Any disputes sent to the Molina Provider Services email boxes will not be logged or worked and will be returned advising the submitter of the correct process for filing a dispute. Click here and review top of page one for further details regarding the correct submission processes.
- Rendering Provider on Professional Claims Submissions: Effective February 1, 2023 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 in order to ensure claims can be properly priced and paid. Click here and review bottom of page two for further details regarding this update.
- Behavioral Health Services: Other Licensed Professionals: Molina released a reminder in accordance with Ohio Administrative Code (OAC) rule 5160-8-05 Behavioral health services-other licensed professionals, the payment amount for a behavioral health service rendered by a community behavioral health center that meets the requirements found in OAC 5160-27-01 is the lesser of the provider’s submitted charge or the amount specified in OAC 5160-27-03. For all other providers of behavioral health services, the payment amount is the lesser of the provider’s submitted charge or the applicable percentage of the amount specified in the appendix to OAC 5160-1-60: 1) for testing, one hundred percent; 2) for a behavioral health service other than testing, the percentage differs according to the provider who rendered it. Click here and scroll to top of page 6 to review the full update.
Buckeye Health Plan Update:
- New Buckeye Health Plan Medicaid Payer IDs: Effective February 1, 2023, the below Buckeye Health Plan payer IDs must be used for claim submission. Click here and refer to page 68 in the 2023 provider manual for further updates.
Humana Healthy Horizons Update:
- Humana Healthy Horizons Payer ID: On Page 44 of Humana Healthy Horizons Provider Manual they reference 61103 as their fee-for-services payer ID. Click here to read all claims information for Humana.
AmeriHealth Caritas Update:
- AmeriHealth Caritas Payer ID: On slide 15 of the AmeriHealth Caritas overview presentation AmeriHealth listed their payer IDs to use for billing starting February 1, 2023.