Next Generation Managed Care
CareSource is pleased to have been selected to continue serving Ohio Medicaid recipients throughout the entire state of Ohio. This page compiles resources to support our providers through the implementation of the Ohio Department of Medicaid’s (ODM’s) Next Generation Managed Care.
ODM’s changes to Medicaid program administration will streamline and simplify administrative tasks between providers and managed care entities (MCEs). These changes will create a single front door approach that focuses on care for the individual member.
- Next Generation of Ohio Medicaid Managed Care – Learn about the Ohio Medicaid Managed Care program.
Staggered Implementation Timeline
Effective Feb. 1, 2023, provider claims submitted to trading partners must include the 12-digit ODM assigned Medicaid member ID (MMIS), else they will be rejected by ODM.
ODM has made the decision to delay the go-live of stage 3 for the Next Generation Managed Care Program until Feb. 1, 2023. At that time, the implementation of Next Generation Managed Care Plans and Electronic Data Interchange (EDI) will go live. At a later date, ODM will launch the Ohio Medicaid Enterprise System (OMES) modules to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers. Please continue to utilize your existing processes to submit claims and prior authorizations until Feb. 1, 2023. Please see the ODM communication regarding timelines for any updates.
ODM has adopted a phased implementation of Next Generation Ohio Medicaid program to ensure members and providers experience a smooth and seamless transition.
- First priority is members and providers supporting CareSource ensures members and providers experience a smooth and seamless transition
- Eligible members will continue to receive the full complement of Medicaid benefits available today
- Providers can continue serving the 3.34 million Ohioans covered by Medicaid, working with current MCOs and the OhioRISE plan using processes and procedures practiced today
Stage 1: On July 1, OhioRISE will begin providing specialized services, which will help children and youth with behavioral health needs and help those that receive care across multiple providers be more coordinated.
Stage 2: On October 1, Centralized Provider Credentialing will begin through the Ohio Medicaid Enterprise System (OMES) Provider Network Management (PNM) module, which will reduce administrative burden on providers. Also, the Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members.
Stage 3a: On Feb. 1, 2023 ODM will be implementing the Next Generation managed care plans and implement the new Electronic Data Interchange (EDI). ODM will also launch the Fiscal Intermediary (FI). The new EDI will begin accepting trading partner fee-for-service (FFS) and managed care claims.
Stage 3a Update: ODM has delayed the attachment submission ((275 claim attachment transaction via Electronic Data Interchange (EDI), from Stage 3a to Stage 3b. As of February 1, when submitting a claim to the new EDI and you need to submit an attachment you will submit the attachments, via the CareSource Provider Portal. CareSource will continue to accept paper claims and submission of claims to the CareSource Provider Portal until Stage 3b goes live (go-live date is TBD).
Stage 3b: TBD: ODM will be implementing the Ohio Medicaid Enterprise System (OMES) modules to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers.
Please see ODM’s communication regarding the timelines and visit the ODM site for any updates.
Review the ODM websites and additional resources:
- Next Generation of Ohio Medicaid Website
- Check out the Resources for Providers webpage on February 1 for the Member Transition provider FAQ document, EDI provider FAQ document, provider one-pager, provider help desk one-pager, trading partner one-pager and trading partner help desk one-pager.
- Check out the ODM Next Generation February 1 Launch Provider Webinar presentation and webinar recording.
Important! Get your OH|ID by October 1 – The First Step Needed to Access New Medicaid Enterprise Systems!
On October 1, Medicaid providers will need a State of Ohio digital identification (OHID) to access the Provider Network Management (PNM) Module and Gainwell Technologies’ single pharmacy benefit manager (SPBM) secure provider portal.
Click here to create an account through the state’s login system, ohid.ohio.gov. Providers needing technical assistance can contact Ohio Medicaid’s Integrated Help Desk (IHD) at 1-800-686-1516. The IHD is open Monday through Friday, 8 a.m.-4:30 p.m.
ODM is implementing a new Provider Network Management (PNM) module and centralized credentialing.
All Ohio Medicaid providers are required to update all of their demographic information on the Provider Master File (PMF) through MITS, prior to the anticipated freeze.
CareSource will process new provider credentialing requests up through Aug. 31, 2022. From Sept. 1, 2022 through Sept. 30, 2022, the provider credentialing request process will be paused and you will not be able to submit new provider enrollment applications until Oct. 1, 2022. After Sept. 30, 2022, to submit a new Ohio Medicaid or Ohio MyCare credentialing request, please visit the PNM Portal.
Upon implementation of the PNM, all Ohio managed care entities (MCEs) will adhere to the PNM file format.
- PNM & Centralized Credentialing – Find detailed information about the implementation of PNM and centralized credentialing.
- Provider Network Management (PNM) Module – Beginning in October 2022, the PNM module will accept Medicaid provider enrollments and carry out centralized credentialing functions. This transition will reduce administrative burden for providers and enable providers to focus on the more meaningful and important work of providing care to members.
Please note: Providers will first need to contract with CareSource before becoming credentialed through the centralized process. Providers can visit www.caresource.com > Providers > Become a Participating Provider and complete the New Health Partner Form.
Effective July 1, 2022 – OhioRISE Launch
ODM is implementing OhioRISE (Resilience through Integrated Systems and Excellence), a specialized managed care program for youth with complex behavioral and multi-system needs. Aetna Better Health of Ohio serves as the OhioRISE specialized managed care plan.
Effective Oct. 1, 2022: Centralized Credentialing & Single Pharmacy Benefit Manager
Ohio Department of Medicaid (ODM) has implemented a single, centralized provider credentialing process at the state level with the go-live of the Provider Network Management (PNM) portal. Under this new process, providers will undergo only one credentialing and recredentialing process at the state level, streamlining credentialing efforts. Credentialing will be handled through the Provider Network Management (PNM) portal.
Single Pharmacy Benefit Manager (SPBM)
ODM is contracting with a new, specialized managed care organization to administer Ohio Medicaid’s prescription drug program. This new Single Pharmacy Benefit Manager (SPBM) will monitor quality, transparency and accountability for CareSource.
Effective Feb.1, 2023: Next Generation Managed Care Plans
On Feb. 1, 2023 ODM will launch the Next Generation Managed Care Plans and implement the new Electronic Data Interchange (EDI). The new EDI will begin accepting trading partner fee-for-service (FFS) and managed care claims. Providers and members will experience no change to how they interact with Ohio Medicaid between now and the February 1 launch.
What is Changing Starting February 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.”)
- If you use a clearinghouse for processing, you must change the Payer ID for transactions with Date of Service on or after Feb. 1, 2023, as shown below:
|837 2010BB NM109
|CareSource OH Medicaid Medical
|CareSource OH Medicaid Vision
|CareSource OH Medicaid Dental
What is Not Changing Starting February 1?
- FFS prior authorizations will continue to be submitted to the PNM portal.
- 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 Claims Submissions and All Prior Authorizations
- Key changes beginning Feb. 1, 2023 include:
- All Next Generation plans will have portals for direct data entry.
- MMIS ID will be the identifying number used for FFS claims processing.
- What will remain the same will include:
- Continuation of using managed care plan portals to direct data-entered claims and prior authorizations
- Plan eligibility accessed through managed care portals
- Continuation of using the PNM portal, which redirects to MITS, as occurs today to submit, adjust, and search FFS claims and prior authorization information.
Following the February Launch
The full implementation of Ohio Medicaid Enterprise System (OMES) modules will be completed, to provide streamlined processes for claims, prior authorizations, and other administrative tasks for providers.
Submitting Claims and Authorizations
ODM is implementing a One Front Door approach to streamline claim and prior authorization submissions. Providers can submit claims and prior authorizations in the following two ways:
- Electronic Data Interchange (EDI) – The claim or prior authorization must be submitted by providers who are trading partners or use an already authorized trading partner or clearinghouse. View instructions to enroll as a trading partner to send and receive EDI transactions to and from ODM-EDI.
- Provider Network Management (PNM) – View information related to the PNM Portal.
One Front Door approach will establish a simplified intake process for transactions and will assist in transitioning claims and authorizations to, as well as receive updates from, CareSource.
Please note: Due to the program go-live delay, dates for submitting claims and authorizations have not yet been determined. For claims and prior authorizations with a date of service prior to the upcoming date ODM will set, the providers can submit through CareSource. For claims and prior authorizations with a date of service on or after the upcoming date ODM will set, providers must submit through the PNM Portal or through EDI (provider is a trading partner, use an authorized trading partner or clearinghouse). EDI 837 and 278 transactions should be used to submit claims and prior authorizations requests.
If you use a clearinghouse for processing, you must change the Payer ID for transactions with Date of Service on or after the upcoming date ODM sets, as below:
|837 2010BB NM109p
|CareSource OH Medicaid Medical
|CareSource OH Medicaid Vision
|CareSource OH Medicaid Dental
For OhioRISE services, providers must send claims and prior authorizations with a date of service on or after July 1, 2022, to Aetna. For claims and prior authorizations with a date of service on or after the upcoming date ODM will set, the provider must submit through the PNM Portal or through EDI (provider is a trading partner, use an authorized trading partner or clearinghouse).
Provider Journey Maps are process maps that visually illustrate various activities required for providers to perform as part of their participation with the Next Generation Medicaid program. They detail common provider activities, explaining the main activities performed by providers beginning Oct. 1, 2022.
We encourage providers to review the Provider Journey Maps to understand from a high-level, how common activities will be performed, and how providers can prepare in advance for these activities.
October 1 – Stage 2 Provider Journey Maps
- OH|ID Registration
- Provider Enrollment and Credentialing in PNM
- Member Eligibility Verification
- Prior Authorization Submission
- Claims Submission
TBD – Stage 3 Provider Journey Maps
Managed Care Rules and Requirements
CareSource expects our network providers to follow Ohio’s managed care rules and requirements. Please familiarize yourself with key requirements to ensure compliance.
- Ohio Administrative Code – Chapter 5160-26 – View managed care plan requirements from the Ohio Administrative Code.
- Ohio Revised Code – Chapter 5167 – View Medicaid managed care requirements from the Ohio Revised Code.
Sample Network Provider Agreement
We have provided sample copies of our provider agreement and addendum.
- CareSource Provider Agreement – View the CareSource Provider Agreement
- Appendix C – Ohio Medicaid Provisions – view provisions applicable to health services rendered to Ohio Medicaid managed care covered persons
Please contact your assigned representative from the CareSource Health Partnership team if there’s anything we can do to help assist your practice with the transition.
You can also contact our Provider Services team at 1-800-488-0134. We are open Monday through Friday from 7 a.m. to 8 p.m. Eastern time.