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
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.
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.
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.
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 – View this brochure to get more information on OhioRISE, including eligibility, covered services, Child and Adolescent Needs and Strengths (CANS) assessments, contact information, and more
OhioRISE Quick Facts
OhioRISE will go live July 1, 2022.
All physical health services will continue to be reviewed by CareSource while behavioral health services will be managed through the OhioRISE provider, Aetna.
OhioRISE members will have a new member ID card with Aetna branding.
Providers will need to send claims and prior authorizations for behavioral health services to Aetna until the Fiscal Intermediary is live in Quarter 4, 2022. Please access the following resources for more information on claims and prior authorization submissions for behavioral health:
Providers interested in contracting with Aetna to provide behavioral health services to children and youth enrolled in the OhioRISE program should contact Aetna Better Health of Ohio at one of the methods listed below:
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.
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 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
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.
- 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.