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.
Overview
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.
Stage 1 Implemented: On July 1, 2022, OhioRISE began 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. Click here to visit the OhioRISE page.
Stage 2 Implemented: On October 1, Centralized Provider Credentialing began 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.
- PNM & Centralized Credentialing– Find detailed information about the implementation of PNM and centralized credentialing.
Stage 3a Implemented: On Feb. 1, 2023 ODM implemented the Next Generation managed care plans and implement the new Electronic Data Interchange (EDI). ODM also launched the Fiscal Intermediary (FI). The new EDI began 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: Future Stage: 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:
Future Stage 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 has established a simplified intake process for claims transactions and will assist in transitioning prior authorization to, and receive updates from, CareSource.
Please note: Dates for the prior authorization function have not yet been determined. If you use a clearinghouse for claims processing, you must change the Payer ID for transactions, as below:
| 837 2010BB NM109p | Description |
|---|---|
| 0003150 | CareSource OH Medicaid Medical |
| CSVIS001 | CareSource OH Medicaid Vision |
| CSDEN001 | CareSource OH Medicaid Dental |
Provider Training
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 are performed.
Provider Journey Maps
- OH|ID Registration
- Provider Enrollment and Credentialing in PNM
- Member Eligibility Verification
- Prior Authorization Submission
- Claims Submission
- Member Eligibility Verification
- Prior Authorization Submission
- Claims Submission
Additional Resources
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.
- Provider Agreement – View the Provider Agreement
- Appendix C – Ohio Medicaid Provisions – view provisions applicable to health services rendered to Ohio Medicaid managed care covered persons
Questions?
Please 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 (ET).