Claims

We want to make it as easy as possible to conduct business with us. In addition to information about how to submit claims and check payments, CareSource offers you tools to find specific information, such as claim status and member coordination of benefits (COB) status. 

Preferred Option: Submit Claims Online

Providers have the option to submit claims through our secure, online provider portal. You can submit claims and any necessary attachments, track claim payments and more. CareSource offers this service at no cost.

SUBMIT CLAIMS ONLINE USING THE CARESOURCE PROVIDER PORTAL

We encourage you to submit claims online to take advantage of the following benefits:

• Faster claim processing
• Reduced administrative costs
• Reduced probability of errors or missing information
• Faster feedback on claim status
• Minimal staff training or cost

Three types of claims may be submitted:

• Professional medical office claims
• Institutional claims

Instructions for Network Providers: Submitting Claims to CareSource

Next Generation MyCare Ohio Program (MCOP) – Claims Information

This section provides essential updates and resources for providers regarding claims submission and the role of OMES.

OMES Overview

The Ohio Department of Medicaid (ODM) has implemented the OMES to enhance the efficiency of the Next Generation MCOP.

The full implementation of the OMES modules is underway, aimed at streamlining processes for claims, prior authorizations, and other administrative tasks for providers. This initiative is designed to enhance efficiency and reduce provider burden.

Key Updates:

• Streamlined Claims and Authorizations:  A One Front Door approach has been established to simplify the submission of claims and prior authorizations.

Submitting Claims and Authorizations

Providers can submit claims and prior authorizations in two main ways:

1. Electronic Data Interchange (EDI):
   • Claims or prior authorizations must be submitted by providers who are trading partners or use an authorized trading partner/clearinghouse.
   • View EDI Enrollment Instructions
2. Provider Network Management (PNM):
   • Access information related to the PNM Portal for additional support.
   • Visit PNM Portal

Important Note: Dates for the prior authorization function have not yet been determined. If you use a clearinghouse for claims processing, please ensure to update the Payer ID for transactions as follows:

Centralized Administrative Responsibilities

To reduce provider burden and promote consistency, ODM has retained administrative responsibilities for the following:

• Centralized Claims Submissions: OMES acts as a single clearinghouse for all medical (non-pharmacy) claims. Providers will submit all medical claims directly to OMES, where they will undergo specified Strategic National Implementation Process (SNIP) level edits before being forwarded to the responsible Managed Care Organization (MCO) for processing and payment.
• Prior Authorization Requests: OMES will serve as the centralized location for prior authorization requests for all medical (non-pharmacy) services, standardizing forms and required documentation to streamline the process.

Centralized Credentialing Approach

ODM has adopted a centralized credentialing approach to enhance provider screening, enrollment, and credentialing activities:

• Single Electronic Application: Providers will utilize a single electronic application for Medicaid enrollment and credentialing, eliminating the need to submit documentation to multiple MCOs.
• Provider Network Management (PNM) System: The PNM system serves as the official record for Medicaid provider data, ensuring consistent maintenance and accessibility of provider information.

Benefits of OMES

The implementation of OMES offers numerous benefits for providers, including:

• Reduced Administrative Burden: Centralized claims submissions and prior authorization requests allow providers to spend less time navigating multiple systems.
• Consistency Across the Program: Standardized forms and processes promote uniformity, simplifying compliance.
• Efficiency in Credentialing: A centralized approach minimizes redundancy and accelerates the enrollment process.

For more information, visit the PNM & Centralized Credentialing page.

Provider Services Team

For further assistance, please contact our Provider Services team at 1-800-488-0134.

Instructions for Out-of-Network Providers: Submitting Claims to CareSource

Ohio has implemented the EDI system alongside the Fiscal Intermediary (FI) as part of the Next Generation MyCare Ohio Program. This guide provides essential steps and essential information for out-of-network providers to submit claims effectively.

1. Understanding EDI and FI
   • Electronic Data Interchange (EDI): The EDI serves as the central hub for all claims-related activities, providing transparency and visibility into care and services.
     • The EDI transaction process has been modernized as part of the Ohio Department of Medicaid’s (ODM) efforts to enhance the OMES.
   • Fiscal Intermediary (FI): The FI processes claims through the EDI. Please note that providers, trading partners, and managed care entities will not interact directly with the FI.
     • All electronic claims for ODM fee-for-service (FFS), managed care entities (MCEs), and OhioRISE will now be exchanged through a single connection with authorized trading partners.

2. Enrollment Requirement
   • All providers billing for services to Next Generation MyCare enrolled members must enroll with ODM through the PNM system. This includes all out-of-network providers, whether out-of-state or unenrolled providers, who are not active providers on the PNM. Providers can submit an application for screening, enrollment, and credentialing through ODM PNM & Centralized Credentialing | Ohio Medicaid Managed Care.

3. Prior Authorization Requirement
   • Non-participating (out-of-network) providers must obtain prior authorization for any services rendered to CareSource members, except in emergency situations.
   • CareSource must ensure all providers, including providers with a single case agreement (SCA), are active provider in ODM’s PNM system for the applicable service.
   • Out-of-network providers must obtain an SCA for payment for services once an authorization is obtained.
     • If the out-of-network provider is not an active provider in ODM’s PNM system, CareSource must verify the provider’s licensure and conduct federal database checks in accordance with 42 CFR 455.436 and must execute a single case agreement with the provider that includes the appropriate Model Addendum.
   • If the provider is not or will not complete an online SCA provider enrollment application to ODM, the provider can complete the ODM 10282 pdf and 10283 ODM10283Fillx.pdf forms to submit to the Next Generation MCOP. This will allow the provider to have a five-year provider agreement.
   • If the provider will not complete the enrollment process or will not complete the ODM 10282 and 10283 forms, the provider can complete the ODM 10295 form pdf. This will allow the provider to have 120-day provider agreement. Providers cannot have more than one 120-day provider agreement.
   • If a provider who is not active in ODM’s PNM system or is not willing or able to become an active provider, by completing the above step and forms, CareSource must terminate the SCA as directed by ODM and must not reimburse the provider for services provided after termination of the SCA.
   • To request prior authorization, call CareSource at 1-833-230-2176.

4. Claim Submission Process
   • Claims can be submitted electronically through the EDI using an ODM-authorized trading partner (TP).
   • When submitting claims, ensure you use the CareSource ODM Payer ID: ‘0021599’ to guarantee proper routing of your claim records.

5. Need Help?

If you have any questions about submitting claims for services rendered to a CareSource member, please contact CareSource Provider Services at 1-800-488-0134.

For more detailed information about the OMES and EDI transactions, please visit the Ohio Medicaid Enterprise System Transactions Overview page.

Get Paid Electronically

CareSource has partnered with ECHO Health, Inc. to deliver provider payments. ECHO offers three payment options:

1. Electronic fund transfer (EFT) – preferred
2. Virtual Card Payment (QuicRemit) – Standard bank and card issuer fees apply*
3. Paper Checks

*Payment processing fees are what you pay your bank and credit card processor for use of payment via credit card.

Enrollment Instructions

Enroll with ECHO for payment and choose EFT as your payment preference for CareSource.

Questions? Call ECHO Customer Support at 1-888-834-3511.

SUBMIT CLAIMS ONLINE VIA PROVIDER PORTAL

Waiver Services Providers

CareSource MyCare Ohio waiver services providers can also submit claims through the service plan in the provider portal. All claims for waiver services reimbursement or appeals for claim denials should be submitted electronically through our provider portal.

If you are unable to log in to the provider portal and access your service plan, use the CMS 1500 Health Insurance Claim form (coming soon) to expedite your claim payment. You can access instructions (coming soon) to complete the form and a list of valid service codes.

You will use this paper claim process until you can log in to the provider portal and access your service plan. 

To ensure that we have the most up-to-date service plan for our CareSource MyCare Ohio members, please fax your service plan to 937-487-0936. This number is only for service plans and NOT claim submissions.

Alternative Option: Paper Claims

Paper claim forms are encouraged only for services that require clinical documentation or other forms to process. Refer to the Provider Manual for instructions to submit paper claims.

Providers can upload paper claims via the provider portal. You can also mail or fax paper claims to the following address:

CareSource
Attn: Claims Department
P.O. Box 8730
Dayton, OH 45401-8730
Fax: 937-224-3388