Next Generation Managed Care

Nex Gen DoctorCareSource 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.

Staggered Implementation Timeline

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, 2022, 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 3: On December 1, ODM will finish implementing the Next Generation program with all seven Next Generation managed care plans beginning to provide healthcare coverage. ODM will also complete the OMES implementation including the Fiscal Intermediary (FI) which will simply and streamline the provider proceed for submitting claims and prior authorizations.

Please note: Dates are driven by ODM and are subject to change.

Please see ODM’s communication regarding the timelines and visit the ODM site for any updates.

Centralized Credentialing

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 August 31, 2022. From September 1, 2022 through September 30, 2022, the provider credentialing request process will be paused and you will not be able to submit new provider enrollment applications until October 1, 2022. After September 30, 2022, to submit a new Ohio Medicaid or Ohio MyCare credentialing request, please visit the PNM Portal.

Provider Network Management (PNM)

Are you ready for changes coming to Ohio Medicaid on October 1? That’s when the Provider Network Management (PNM) module is live and accepting provider enrollment applications and existing providers can update and manage demographic updates! Pre-register with your OH|ID for the PNM modules by September 23 so you’re ready for changes coming soon.

Fee for Service providers that currently submit claims and prior authorizations directly to ODM: Effective October 1, the PNM is your entry point for claims submission and prior authorization submission with a redirect to the Medicaid Information Technology System (MITS) until Dec. 1, 2022.

If you miss the September 23 deadline:

Providers who miss the September 23 pre-registration can create an Ohio Identification (OH|ID) account through the state’s login system, ohid.ohio.gov, at any time. Once an account has been created, providers can securely access Medicaid’s enterprise systems.

Providers are encouraged to use the resources below to set up their account:

Upon completion of this project, all Ohio managed care entities 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 CareSource.com > Providers > Become a Participating Provider and complete the New Health Partner Form.

OhioRISE

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.

CareSource will continue to provide physical health care coverage for OhioRISE plan members. We will support the OhioRISE program by taking an active role in collaborating and coordinating with Aetna Better Health of Ohio and other stakeholders identified as members of the youth’s Child and Family Team on the integrated physical and behavioral health care of shared members..

    • OhioRISE Overview – Access information about the OhioRISE program
    • OhioRISE Community and Provider Training – Access materials and register for upcoming OhioRISE education seminars
    • OhioRISE Information Brochure – Use this brochure with youth and families to provide high-level information about the OhioRISE program that helps with understanding the major components of the program. Information is tailored to youth and families that explains about eligibility, covered services, CANS assessments, how to get more information on OhioRISE, contact information for questions, and more.
    • Navigate OhioRISE Community Partner Flier – View this flier for more comprehensive information on OhioRISE that community partners can use when talking with youth and families about the details of the program. This flier provides more in-depth details about eligibility, covered services, CANS assessments, scheduling appointments, and more.

OHRise Info Gr

CANS Assessment

The Child and Adolescent Needs and Strengths (CANS) assessment is a support tool in the clinical decision-making process to determine eligibility into OhioRISE and level of care and service planning.

  • CANS Resources – View information on the CANS tool, how to become a CANS assessor, and training information.
  • OhioRISE CANS Assessment Fliers:
      • Navigate Flier for CANS Assessors – View this flier for information on the OhioRISE program and implications on the CANS assessment for program enrollment. This flier can be used across all settings.
      • Navigate Flier Youth and Families About the CANS Assessment – Use this flier with youth and families to explain the OhioRISE program, CANS assessments, and the role of CANS in determining OhioRISE eligibility. This flier can be distributed by CANS assessors prior to or at the time of a CANS assessment.

Care Coordination Portal Access

Training has been developed to assist OhioRISE Community Care Entity (CCE) and Care Management Entity (CME) providers with accessing and navigating the Care Coordination Portal for member information, including how to resolve access issues, how to send and receive messages in the system, and identifying assigned care management staff for members in care coordination. Providers can access the training here.

Submitting Claims and Authorizations

ODM is implementing a One Front Door approach to streamline claim and prior authorization submissions. Providers can submit claim and prior authorization in the following two ways:

  • EDI – view instructions to enroll as a trading partner to send and receive EDI transactions to and from ODM-EDI
  • Fiscal Intermediary – view information related to the fiscal intermediary 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: Providers must send claims and prior authorizations to Aetna between July 1, 2022 and the go-live date of the fiscal intermediary in 4th Quarter, 2022. Once the fiscal intermediary is live, providers must submit claims and prior authorizations through the fiscal intermediary.

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.

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.

Sample Network Provider Agreement

We have provided sample copies of our provider agreement and addendum.

Questions?

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 8 a.m. to 6 p.m. Eastern time.