Next Gen Contract Information
Next Generation Managed Care
Buckeye Health Plan 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.
- Next Generation of Ohio Medicaid Managed Care – Learn about the Ohio Medicaid Managed Care program.
Latest information regarding the ODM Next Generation Contract for July 1, 2022.
The Ohio Department of Medicaid (ODM) will begin to launch its Next Generation Medicaid program beginning July 1, 2022, with the implementation of OhioRISE, a coordinated care program for children with complex behavioral health needs. Other Medicaid programs will be implemented in the following months on a staggered basis to keep the focus on the individual and honor member choice to allow for a smooth transition.
This staggered start ensures continuity of care, limits confusion, and reduces complexities surrounding the anticipated end of the federal public health emergency (PHE) and provides the necessary time for provider testing and training.
The phased implementation will occur in three stages:
Stage 1: On July 1, OhioRISE will begin to provide coordination and specialized services to help children and youth with behavioral health needs who receive care across multiple systems.
Stage 2: In October 2022, 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: During the last three months of 2022, ODM will finish implementing the Next Generation program with all seven Next Generation managed care plans beginning to provide healthcare coverage under the new program. ODM will also complete the OMES implementation including the Fiscal Intermediary (FI) which will simplify and streamline the provider process for submitting claims and prior authorizations.
Ohio Medicaid is committed to launching the Next Generation Medicaid correctly. The phased timeline assures no disruption to members’ care or provider support.
For full details of ODM's announcement, visit Ohio Medicaid’s Next Generation program to launch July 1 with OhioRISE | Medicaid
The Ohio Department of Medicaid (ODM) along with the Department of Developmental Disabilities (DODD) and Ohio Department of Aging (ODA) are in the process of implementing a new Provider Network Management (PNM) module and Centralized Credentialing effective July 1, 2022.
In preparation for the rollout of the new system, ODM is expected to implement a freeze period some time in May. During the freeze, ODM will not process or update information on the MITS system as they migrate current information over to the new PNM file.
Once the migration is complete, all Managed Care Plans will be expected to mirror the information in the PNM file. Files will be shared and loaded onto the Buckeye Health Plan system to reflect only the information that is on file through the State of Ohio.
We are asking all providers to update their information on the Provider Master File (PMF) through MITS prior to the anticipated freeze. MITS Provider Directory
For more details regarding the new PNM and centralized credentialing please visit the website link PNM & Centralized Credentialing | Ohio Medicaid Managed Care.
Thank you in advance for taking the time to update all your demographic information.
Slides for Providers Submitting PA and Attachments for MCE's via PNM Portal - Coming Soon
Helpful Links
- Centralized Credentialing
- ODM is implementing a new Provider Network Management (PNM) module and centralized credentialing.
Don't Forget
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.
- MITS PROVIDER DIRECTORY
- Centralized Credentialing FAQ
- 10 Things you should know about Centralized Credentialing
- Differences between Enrollment and Credentialing
- Training - The training is expected to begin in May 2022 and additional details will be forthcoming.
- PNM Provider Network Module Centralized Credentialing Template | PowerPoint Presentation (ohio.gov)
Fiscal Intermediary
ODM is implementing a fiscal intermediary (FI) to streamline claim and prior authorization submissions. 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, Buckeye. Providers will be required to submit Medicaid claims and request for prior authorization to the fiscal intermediary.
Buckeye's OhioRISE Overview Website Page
OhioRISE Training
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 Buckeye.
- 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
Buckeye 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
- OH Participating Provider Agreement (PDF)
- NextGen Buckeye Medicaid Base Provider Agreement. This is to give providers who are not currently contracted with Buckeye an idea of our participation requirements.
- OH Provider Product Attachment (PDF)
- Regulatory Amendment adding new NextGen required contract language to provider agreements. This is to give providers who are currently contracted with Buckeye an idea of the new NextGen participation requirements.
Questions?
Contact our Provider Services team at 866.296.8731. We are open Monday - Friday from 8 a.m. to noon and 1- 5 p.m.