Skip to Main Content

EDI: Electronic Data Interchange

From ODM: November 3, 2022

On February 1, 2023, the Ohio Department of Medicaid (ODM) will implement the new Electronic Data Interchange (EDI) module as part of the Next Generation program. The new EDI vendor is Deloitte. The EDI will be the exchange point for trading partners on all claims-related activities. Buckeye Health Plan providers are expected to educate and prepare their trading partners for the February 1 launch. To assist in preparations, ODM compiled a list of important changes to keep in mind.

Important changes for all EDI claims

With the launch of the new EDI vendor, Deloitte, changes in claim submission will be required for the trading partners to exchange transactions in the new EDI. Please note that MyCare is not included in the Next Generation program and will continue to be submitted using the current processes. Key changes are as follows:

  • Billing providers must be enrolled with ODM as a provider type who is permitted to be a billing provider and be paid for services. Non-billing provider types must be affiliated with the billing provider on the claim. Claims without appropriate affiliation will be rejected on an 824 transaction.
  • Dates of service after February 1 must be submitted through the new EDI vendor.
  • Fee-for-service (FFS) claims may only include one Rendering Provider per claim. Different rendering providers at the detail are no longer acceptable for FFS claims.​
  • Each claim must include the internal managed care payer ID listed in the ODM Companion guides so the managed care entity (MCE) can route claims appropriately within their systems.
  • Each claim must also use the 12-digit, ODM-assigned member ID even if one of the MCEs is the destination payer.
  • Separate files must be submitted using the Receiver ID assigned by ODM for each plan, e.g., a CareSource Payer file can only contain claims for members covered by CareSource.
  • Providers who wish to receive an 835 Electronic Remittance Advice (ERA) must use the ODM-06306 835 Designation form to choose the ODM-authorized trading partner to receive the 835 on their behalf. Providers who are already enrolled for the 835 with ODM do not need to re-enroll. Please note that this enrollment will also direct all 835s from the Medicaid managed care plans. 
  • Upon claim submission, EDI will validate code sets. Claims with invalid codes will be rejected with an 824 transaction.
  • Deloitte EDI will provide an attachment+control file option for trading partners who do not have the EDI 275 attachment transaction built yet.
  • Billing providers must be enrolled with ODM as a provider type who is permitted to be a billing provider and be paid for services. Non-billing provider types must be affiliated with the billing provider on the claim. Claims without appropriate affiliation will be rejected on an 824 transaction.

Important changes for all EDI prior authorizations

Beginning February 1, 2023, all prior authorizations (PA) for FFS must be entered via the Provider Network Management (PNM) module. MyCare prior authorizations will continue to be submitted using the current processes. Prior authorizations for members covered by the managed care entities can be submitted either using the PNM module or by using the EDI 278 transaction in the new EDI.

Additionally, attachments that are submitted to the new EDI to support PAs and forwarded to the MCE must use the attachment+control file option. Deloitte EDI will provide an attachment+control file option for trading partners who do not have the EDI 275 attachment transaction built yet.

Information about the PNM module

For awareness, when the new EDI launches, providers will still have the option to direct data enter (DDE) their claims. DDE will be accessible to providers via the PNM on February 1, 2023. More information regarding the PNM can be found on the Ohio Medicaid Managed Care PNM & Centralized Credentialing webpage.

As we approach the February 1, 2023, launch, trading partners will need to work with their providers to determine the specific changes that may be needed to their systems and staff training. We hope this information will help in educating and preparing your providers. More informatoion can be found on the Ohio Medicaid Enterprise System website

EDI Support   

EDI-TP-Comments@medicaid.ohio.gov