Skip to Main Content

What You Need to Know

OhioRISE Provider Enrollment During System Transition

(Aug. 1, 2022-Sept. 30, 2022)

In preparation for the Oct. 1 launch of the new Provider Network Management (PNM) module, which will reduce administrative burden on providers, ODM will not accept new provider enrollment applications through the MITS Provider Enrollment System starting Aug. 1. 

See the July 29: OhioRISE Provider Enrollment During System Transition Guidance document.

Submitting claims to Aetna OhioRISE for RISE covered services, and all other services to Buckeye,  Mixed Services Protocol documentation should be referenced.

Denials of claims to OhioRISE on Buckeye remittances will include CARC 301; RARC N216.  Aetna OH Rise will be identified as the payer on the provider’s 835 remittance advice.

OhioRISE (Resilience through Integrated Systems and Excellence) | Ohio Medicaid Managed Care

 

Effective 7/1/22, all youth that experience a psychiatric or substance use disorder inpatient admission with a principal behavioral health diagnosis will be automatically enrolled into OhioRISE on day 1 of the admission.

  • The behavioral health diagnoses include the following codes: F0150-F99, R440-R443, R450- R4582, R45850-R4589, R4681-R4689, or Z72810-Z72811.
  • The reimbursement DRGs include the following: 740, 750-760, 770 or 772-776.
  • An inpatient claim type with a principal diagnosis code or reimbursement DRG outside of the behavioral health range is the responsibility of Buckeye.
  • Notes:
  • If the individual turns 21 during the psychiatric inpatient stay, the OhioRISE Plan is responsible for the hospital claim (admit through discharge)
  • If individual is transferred to/from medical to/from distinct part psychiatric unit, the psychiatric stay is billed to the OhioRISE Plan and medical is billed to the individual’s MCO (or FFS).
  • Three-day roll-in: If individual is enrolled in OhioRISE at the time of the outpatient visit and there is a subsequent psychiatric inpatient admission at the same hospital, the outpatient visit will be rolled into the inpatient admission; if not already on the OhioRISE Plan and has a subsequent psychiatric inpatient admission, the individual’s MCO (or FFS) is responsible for the outpatient services (services billed as OPHBH at general hospitals are excluded from the three-day roll-in).

Aetna OhioRISE Claims - Practitioner Modifiers Update

This MITS BITS provides an update to and replaces the communication sent on June 16, 2022, regarding the use of practitioner modifiers on Aetna OhioRISE claims submitted by community behavioral health providers.

In preparation for the launch of OhioRISE on July 1, 2022, and in preparation for the Ohio Department of Medicaid’s (ODM’s) implementation of the “front door” for claims submission later this year, ODM and Aetna Better Health of Ohio have agreed to align OhioRISE practitioner modifier requirements for outpatient and professional claims with those used in ODM’s fee-for-service program.

In accordance with this set of changes, the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page, were updated today. Both documents now describe Aetna’s practitioner modifier requirements for outpatient and professional claims as aligning with those in ODM’s fee-for-service program.

With the implementation of this update in Aetna’s billing requirements, Aetna will NOT REQUIRE practitioner modifiers on the following types of claims, unless the rendering practitioner holds multiple licenses or credentials with differing scope of practice (see section below).

  • Community mental health agency claims (provider type 84).
  • Community substance use disorder treatment provider claims (provider type 95).
  • OhioRISE care management entity (CME) claims.
  • Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
  • Outpatient hospital claims submitted for Enhanced Ambulatory Patient Groups (EAPG) reimbursement.

In alignment with ODM fee-for-service policy, Aetna will require practitioner modifiers on outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement. Aetna’s OPHBH practitioner modifier requirements will mirror ODM’s fee-for-service requirements.

Practitioners with multiple licenses or credentials

Aetna will require rendering practitioners holding multiple licenses or credentials with differing scopes of practice to use ODM’s requirements for enrollment and claims submission, including:

  • Provider enrollment with a multi-license specialty.
  • Rendering provider reporting their additional licensure/credentials on claims.
  • Use of modifiers identified on ODM’s dual licensure grid, which can be found on https://bh.medicaid.ohio.gov/manuals.

Aetna will be reconfiguring its claims engine to incorporate the requirements outlined above. Until this reconfiguration is complete, Aetna will need to process some claims manually. Providers will not be required to resubmit or adjust claims at a later date if their claims are processed manually because of Aetna’s reconfiguration timeline.

As noted in a previous MITS BITS, other changes were made to the OhioRISE Provider Enrollment and Billing Guidance and the OhioRISE Care Management Entity Manual on June 14, 2022, including some clarifying language and corrections made based on stakeholder feedback. Those changes are noted in the version logs at the beginning of each document.

The Medicaid Behavioral Health Provider Manual was also updated on 6/14/2022 to clarify that CANS assessments must be entered in Ohio’s CANS IT system only to establish and maintain OhioRISE eligibility.

Questions?

___________________________________________________________________________

June 16, 2022

In preparation for the launch of OhioRISE on July 1, 2022, the Ohio Department of Medicaid and Aetna have made some changes to the OhioRISE Provider Enrollment and Billing Guidance and the Care Management Entity (CME) Manual, both available on the OhioRISE Resources for Community Partners and Providers page. Changes were made to include a practitioner modifier table and to clarify Aetna’s practitioner modifier requirements for professional and outpatient claims.

Practitioner modifiers are REQUIRED by Aetna on the following claims, for each service line and all practitioner types: 

  • Community mental health agency claims (provider type 84).
  • Community substance use disorder treatment provider claims (provider type 95).
  • CME claims for CANS and initial comprehensive assessment services only (CMEs do not use practitioner modifiers on ICC/MCC claims).
  • Outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement.

Practitioner modifiers are NOT REQUIRED by Aetna for the following claims: 

  • CME claims for Intensive Care Coordination and Moderate Care Coordination (see the updated OhioRISE CME Manual for more information, practitioner modifiers are NOT allowed on ICC/MCC claims, but CMEs should use them on claims for CANS and comprehensive assessments).  
  • Other professional and behavioral health services reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).
  • Outpatient hospital claims submitted for Enhanced Ambulatory Patient Group (EAPG) reimbursement.

To allow providers additional time to configure claim systems to accommodate Aetna’s practitioner modifier requirements, Aetna is offering a grace period for practitioner modifier use. 

For claim submission dates from July 1, 2022, until Aug. 15, 2022, providers have three options:  

  • Option 1: Providers may submit claims requiring practitioner modifiers using the practitioner modifiers defined in the updated billing guidance document. 
  • Option 2: Providers that need additional time to configure their claims systems may submit claims to Aetna without practitioner modifiers during the grace period. For claims that would otherwise deny because no practitioner modifier is included, the claims will be pended during the grace period and Aetna will process manually. Providers using this option will not be required to resubmit or adjust claims at a later date to add practitioner modifiers.  
  • Option 3: Providers may hold claims and submit to Aetna after their systems are configured to include the practitioner modifiers where required, as long as timely filing requirements are met. Aetna accepts claims for 365 calendar days from the date of service.  

Other changes also have been made to the OhioRISE Provider Enrollment and Billing Guidance and the Care Management Entity (CME) Manual, including some clarifying language and corrections made based on stakeholder feedback. These changes are noted in the version logs at the beginning of each document.  

The Medicaid Behavioral Health Provider Manual also has been updated to clarify that CANS assessments must be entered in Ohio’s CANS IT system to establish and maintain OhioRISE eligibility.

Questions regarding OhioRISE may be submitted to the support mailbox: OhioRISE@medicaid.ohio.gov.  

Questions regarding Medicaid Behavioral Health Policy may be submitted to
Bh-Enroll@medicaid.ohio.gov

In preparation for the launch of OhioRISE on July 1, 2022, the Ohio Department of Medicaid is providing OhioRISE provider enrollment and billing guidance.

The OhioRISE program covers a range of behavioral health (BH) services for youth that are comprised of existing, enhanced, and new behavioral health and care coordination services. This guide is intended to share policies related to billing for the new and enhanced OhioRISE services. Existing behavioral health services will be covered in accordance with the OhioRISE Mixed Services Protocol and will be billed consistent with the billing policies outlined in the appropriate provider type billing guidelines.

You can find the guidance on the OhioRISE website and here OhioRISE+Provider+Enrollment+and+Billing+Guidance.pdf.


Member ID Cards Through September 30, 2022

2022 Member ID Card - OhioRISE Without Coordinated Services Program (CSP) Enrollment

2022 Member ID Card - OhioRISE With Coordinated Services Program (CSP) Enrollment

Member ID Cards Beginning October 1, 2022

2022 Member ID Card - OhioRISE With Coordinated Services Program (CSP)
as of October 1, 2022 - Front

2022 Member ID Card - OhioRISE Without
Coordinated Services Program (CSP) as of October 1, 2022 - Front

2022 Member ID Card - OhioRISE With Coordinated Services Program (CSP) as of October 1, 2022 - Back

2022 Member ID Card - OhioRISE Without
Coordinated Services Program (CSP) as of October 1, 2022 - Back