Important Notices & Updates
Important Notices
Claims Auditing – Custom Fitted or Custom Fabricated Prosthetics or Orthotics
On March 27, 2023, we notified our providers that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. For Phase 1, claims received on or after July 1, 2023, providers may experience a slight increase in written requests for medical record submission prior to payment for Custom Fitted or Custom Fabricated Prosthetics or Orthotics. We will be requesting medical records to verify documentation that supports high-dollar custom DME codes billed by the provider. These requests will come from Optum and will contain instructions for providing the documentation.
Notification for Buckeye Health Plan, Wellcare By Allwell and Ambetter Providers:
We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. This is a notification that we will begin performing additional prepayment claim reviews on July 1, 2023, using Optum’s Comprehensive Payment Integrity (CPI) tool. As a result of these prepayment claim reviews, providers may be asked for medical records and billing documents that support the charges billed.
We utilize widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. The prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. A provider’s order must be present in the medical record to support all charges, along with clinical documentation to support the diagnosis and services or supplies billed.
If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.
If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.
Please contact the applicable Provider Services listed on our home page or your Provider Engagement Administrator if you have any questions.
ODM Pause on Provider Agreement Revalidation/Recredentialing
The Ohio Department of Medicaid (ODM) paused provider agreement revalidations/recredentialing by pushing out all pending provider revalidation due dates in the Provider Network Management (PNM) module by 180 days. Dates were pushed out in the system during the week of February 6, 2023.
The updated due dates applied to all providers who had not begun the revalidation process prior to the week of February 6, including those that already displayed the “Begin Revalidation” button. This button indicated the provider had entered the 120-day period before revalidation is due. A provider’s revalidation date is indicated by the Medicaid Agreement End Date field in PNM. ODM issues a revalidation notice to the provider 120 days in advance of that date, including display of the “Begin Revalidation” button within their PNM account.
As a provider, what action do I need to take?
- If you do not see the “Begin Revalidation” button in the provider record, you do not need to do anything. The update will move the dates out another 180 days.
- If you do have the “Begin Revalidation” button, this means you are within the current 120-day window for revalidation.
EXCEPTION: If you started a revalidation prior to the week of February 6, 2023, it must be completed and submitted, as this change cannot be applied to providers that were already in the revalidation process.
Providers are strongly encouraged to avoid potential enrollment delays by submitting revalidation applications early in the process.
For more information: For technical support or assistance, contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2) or email IHD@medicaid.ohio.gov.
To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page on the Next Generation website. ODM will provide additional guidance but the 5/11/23 date is the likely date that PHE is lifted which sets in motion various timelines to unwind from provider flexibilities. ODM will realign all revalidation dates accordingly and the MCE will access that information from the daily PMF.
A message from ODM
Hello CMC Practices,
Enrollment for the Comprehensive Maternal Care (CMC) alternative payment model program is open from October 10 to November 7. To participate, you must complete an enrollment in the Provider Network Management (PNM) module for the CMC program. We are aware of issues some users are experiencing when using the PNM module for the CMC program. Follow the guidance and troubleshooting tips below if you encounter problems.
What to do if you encounter an error while enrolling in CMC:
- Remember an OH|ID is required to access the PNM module. If you do not have an existing OH|ID, you will need to create one to access the PNM module.
- Access the PNM module by clicking here.
- Click on the “Don't Have an Account Click Here” link on the PNM homepage. You will be redirected to the OH|ID site to create your new account.
- Setup the Administrator & Agent roles in the PNM module or verify your role within the PNM module. Agents need the “CPC Agent” role assigned to them for each ID they need to complete the enrollment actions under.
- Is the Agent or Administrator looking under the correct provider file?
- The user must be looking under the billing Medicaid ID provider file that received the invitation. If a Medicaid ID did not receive an invitation, the CMC enrollment link will not exist.
- Does the Agent or Administrator have the CMC entity provider file (CMC Medicaid ID) on their dashboard?
- If not, then the administrator has not assigned the “CPC Agent” role (yes that's correct) for that Medicaid ID file yet. If the Administrator not have that same Medicaid ID on their dashboard, then the Administrator will have to have the Medicaid ID assigned to them by contacting the Integrated Help Desk at 800-686-1516 option 3 then 2, or email: IHD@medicaid.ohio.gov.
For more information
If you have additional questions, please direct them to the Integrated Help Desk at 800-686-1516 or email: IHD@medicaid.ohio.gov. Help desk hours are extended from Monday, October 10 through Friday, October 14 and will be 7 a.m. – 7 p.m. ET. Regular weekday hours of 8 a.m. – 4:30 p.m. ET will resume October 17.
If you want to ensure receiving CMC specific communications, sign up for the new CMC distribution email list, which can be found on our ODM subscribe form!
As the healthcare industry continues to grow and change, Buckeye Health Plan is expanding our Provider Advisory Council (PAC) to ensure we are at the forefront of understanding and meeting the needs of our provider partners. Together, we discuss how to best serve our most vulnerable members, your patients, and any barriers you may be encountering.
Our PAC meets 2-4 times per year, based on volume of discussion points and industry activity. There are no participant requirements or guidelines, just our participating provider’s sharing their thoughts and expertise in delivering quality care. Whether you are advocating for your region, patients, practice, or your own specialty—all thoughts are welcome.
Primary responsibilities of the PAC:
- Provide input and recommendations to Buckeye Health Plan about quality aspects and activities of the plan to improve member well-being through healthy behaviors and disease prevention and self-management of chronic conditions.
- Gain input to help develop evidence-based interventions to help improve care for members.
There will be Buckeye Health Plan attendance with other medical directors and Network Development staff.
Our next meeting is scheduled for September 9, 2022, at 7:00 a.m. EST via Teams.
If you would like to participate in that Provider Advisory Council meeting, or future meetings, please notify us via email at: buckeyerequests@centene.com. We look forward to hearing from you.
Electronic Visit Verification (EVV) – Providers rendering EVV-eligible services should monitor their remittance advices or our web portal for EVV error information codes on claims. CARC = 45; RARC = N363. The information-only codes at some point will be enforced through ODM and result in claim denials.
Mixed Services Protocol: Submitting claims to Aetna OhioRISE for RISE covered services, and all other services to Buckeye, Mixed Services Protocol documentation should be referenced.
LPN Renewal began July 1, 2022 and continues through October 31, 2022
LPN license renewal begins July 1, 2022. In May 2022, the Board will begin sending renewal information through eNews and social media, and please check the Board of Nursing for up-to-date renewal information.
Important renewal reminders
- Renew before September 15, 2022 and pay a fee of $65.00 plus the $3.50 state transaction fee.
- Renew September 16- October 31, 2022 and pay a fee of $115 plus the $3.50 transaction fee.
- If you do not renew by October 31, 2022, your license will lapse on November 1, 2022. You will not be authorized to practice as an LPN until you license is reinstate.
Renewal will be completed using the Ohio eLicense system, a comprehensive professional regulatory license system used by a variety of state licensing boards, the same system used during the last renewal period. It is estimated more than 55,000 licenses will be renewed this year. The Board encourages early renewal to prevent processing issues that could lead to delays. Licensees may use a computer in the Board office to renew online on business weekdays between 8:00 a.m. and 5:00 p.m.
Be prepared
Don’t wait to renew! Incomplete applications will not be accepted by the online system. Waiting until a deadline and realizing you do not have all the information needed to complete the application may prevent you from renewing.
Additional Information May Be Required
- If you are asked to provide documentation of citizenship, court documents or other information that may be required as part of your application, please be prepared to upload the documents electronically through the online system.
- If all required documents are not provided electronically, the renewal application is incomplete and will not be processed.
- No hardcopies of court documents or other information required as part of your application will be accepted.
Continuing Education Renewal Requirements
- You must complete the continuing education (CE) requirements by October 31, 2022, to maintain licensure.
- You are not required to submit documentation of CE when you renew your license, but you must attest on the renewal application that you met or will meet the CE requirement by October 31, 2022. Failure to comply with CE requirements may be grounds for disciplinary action. For more information on CE, please refer to the Continuing Education FAQ document on the Board website.
Pay by Credit or Debit
- The State of Ohio charges a $3.50 transaction fee in addition to the application fee.
- Fees must be paid online at the time of renewal using a Mastercard, VISA or Discover credit or debit card.
- Prepaid Mastercard, VISA or Discover cards may be used to pay renewal fees. Reminder, you must have sufficient funds on the prepaid card to cover all associated renewal fees.
- If the fee is not paid when you submit your application, the application will be incomplete and will not be processed.
- All fees are non-refundable.
Posted July 22, 2022
The Ohio Department of Medicaid will hold the annual public forum on the Substance Use Disorder (SUD) 1115 Demonstration Waiver during the upcoming SUD 1115 Stakeholder Advisory Committee. The meeting will be held virtually at 1 p.m. on Aug. 16, 2022.
Any interested party may attend the Aug. 16 meeting via the Aug. 16 SAC Meeting Link.
The public forum will open immediately following the regular agenda of the Stakeholder Advisory Committee. During the public forum, any interested party is invited to offer comments on any aspect of the waiver. Written comments may also be submitted before or after the public forum.
Instructions to provide verbal comments during the public forum:
- Select the “Reactions” button at the top of the Teams screen.
- From the drop-down, select the “Raise Hand” button. A purple line will appear under the icon.
- Once your name is called, unmute yourself by pressing the “Mic” button. The slash on the icon will disappear indicating you are unmuted.
- Once you have spoken, place yourself back on mute by pressing the “Mic” button again. A slash on the icon will reappear indicating you are muted.
- Remove your “Raise Hand” by following Steps 1 & 2 above again. The purple line under the icon will disappear.
Instructions to provide written comments before or after the public forum:
Written comments or questions may be sent via email to MCD_SUD1115@medicaid.ohio.gov.
PLEASE NOTE: Beginning Aug. 16, all SUD 1115 Stakeholder Advisory Committee meetings will be held via Microsoft Teams (not via GoToWebinar).
Any questions regarding this communication may be submitted to BH-Enroll@medicaid.ohio.gov
Claims submitted after 12:00 p.m. on Friday, June 24,, will be held for processing until the Ohio Administrative Knowledge System (OAKS), the state’s accounting system, is up and running for state fiscal year (SFY) 2023 (beginning July 1). The Ohio Department of Medicaid anticipates issuing final provider payments for SFY 2022 on Wednesday, June 29, however, fiscal year-end processing may cause a delay in payment until OAKS is up and running for SFY 2023. The Ohio Department of Medicaid anticipates issuing the first payment of SFY 2023 to providers on July 8. Please note, as a result of fiscal year-end processing and the July 4 holiday, OAKS processing may experience a brief delay and payment may not be made until the week of July 11.
Due to the recent Abbott infant formula recall and related formula shortages, the ODH WIC Program is temporarily allowing several flexibilities, including more formula options (brands and container sizes) for standard milk and soy-based infant formulas. Additionally, the Ohio WIC Program is temporarily allowing the issuance of store brand hypoallergenic infant formulas.
See the notices:
Beginning May 1, 2022, inpatient stays of less than 48 hours may be converted to an observation status unless one of the exceptions listed within Clinical Policy: Short Inpatient Hospital Stay are met. You will find a copy of the policy in the Clinical and Payment Policies section of Provider Resources. The Short Inpatient Hospital Stay policy is applicable to Medicare (Wellcare By Allwell) and Marketplace (Ambetter) lines of business.
Posted January 24, 2022
Ohio Department of Medicaid Now Requires Medicaid ID Number
What’s Happening:
Compliance with new federal rules 42 CFR 438.602.
The Ohio Department of Medicaid (ODM) currently requires any provider that submits a claim for a Medicaid patient to be enrolled with ODM and have a Medicaid ID number. The provider must be enrolled on the date of service billed.
Effective March 1, 2022, Buckeye Health Plan will be enforcing this ODM requirement for claims received on or after March 1, 2022. Providers will be required to have an active Medicaid ID on file with Buckeye Health Plan for all claims, regardless of the date of service.
How to Apply for or Revalidate a Medicaid ID number:
For Providers without an active Medicaid ID number or need to revalidate their Medicaid number, follow the steps below to apply for a new Ohio Medicaid number
- Go to the MITS Portal at: Providers (ohmits.com)
- Select “Provider Enrollment Application”,
- Select the “I need to enroll as a provider to bill Ohio Medicaid option.
- Follow the system prompts and provide the requested information.
- When you have completed all steps, please submit your application.
You can view the status of your application online by visiting the following link: Enrollment Tracking Search (ohmits.com). You will need to provide your Application Tracking Number (ATN) and name used to complete the application to check the application status.
To contact ODM, please call 800-686-1516.
What do I do next?
Nothing. Once you have received your Medicaid ID number, it will automatically update in our system when you submit a claim. If you have questions, please contact Provider Services at 1-866-296-8731.
For your reference:
Recently, you may have received a letter from Buckeye re: the 2019 Episodes of Care Results and outstanding 2018 negative incentive amounts.
Due to a system error, the breakdown by episodes were mis-labeled. We want to assure you that this issue was with the way the episodes were labeled, not with the total incentive. The total incentive indicated on the letter is correct.
If you received a check, you may safely deposit it. If your letter indicated a negative incentive, that total amount is also correct, and will be withheld from claims payments as indicated in the original letter. We will be sending a revised letter with the correct breakdown by episode in the next few days. We apologize for the confusion this error caused, and assure you that the total incentive amount indicated on the letter is accurate.
Capping Hydration Codes Billed with Modifier 59
Hydration Codes impacted: 96360 – 96368 currently receiving denials “ys” and “xX” when billed with modifier 59.
Reducing denials by more than 50%, the health plan will implement a cap for billed charges at $200 for Medicaid and $150 for Medicare.
- This is a system edit, where if the services are billed with modifier 59, under the billed charge limit, the service will pay without requiring medical records.
- It is based on the code billed, not specific claim type ER, etc.
- Timeframe for configuration: It is estimated that it will take approximately 8-weeks to be in production.
- While configuration is in process, we will pull a claims report for DOS January 1, 2021 to December 31, 2021 and have them reprocessed.
- After the system update, we will create another project to capture any claims with dates of service in 2022.