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.
ODM is implementing a new Provider Network Management (PNM) module and centralized credentialing.
In preparation, ODM will implement a freeze period in May 2022, during which time ODM will not process or update information on the Medicaid Information Technology Information System (MITS) as information is transitioned to the new PNM file and format.
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.
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 – Coming soon.
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 to collaborate and coordinate the care for the child- and family-centered care plan and child and family team as needed.
- OhioRISE Overview – Access information about the OhioRISE program.
- OhioRISE Community and Provider Training – Access materials and register for upcoming OhioRISE education seminars.
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.
- Child and Adolescent Needs and Strengths (CANS) Resources – View information on the CANS tool, how to become a CANS assessor, and training information.
Submitting Claims and Authorizations
ODM is implementing a fiscal intermediary (FI) to streamline claim and prior authorization submissions via the Provider Network Management (PNM) portal. The FI will serve as the central point of intake for transactions and will assist in transitioning claims and authorizations to, as well as receive updates from, CareSource. Providers will be required to submit Medicaid claims and request for prior authorization to the PNM portal.
- Fiscal Intermediary – View information related to the fiscal intermediary 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.
- Ohio Medicaid Single Pharmacy Benefit Manager (SPBM) – Find additional information about the SPBM.
- ODM Email Box – Contact ODM for questions on the SPBM.
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 8 a.m. to 6 p.m. Eastern time.