Etactics Comments on Upcoming 12/1/2022 Changes for Medicaid OH and Managed Care Entities (MCE) 

10/19/2022

Effective 12/1/2022, Ohio Department of Medicaid (ODM) is mandating new EDI Routing as a phase 3 of their Next Generation Program. All claims for Medicaid OH Fee For Service (FFS) and their Managed Care Entities (MCE) with a Date of Service 12/01/2022 or AFTER will be sent by Etactics to Ohio Medicaid for Pre-Processing. Ohio Medicaid will then forward claims to the MCE for processing and adjudication.

All claims received AFTER 12/01/2022 with Dates of Service BEFORE 12/01/2022 must be routed directly to the Managed Care Plan as they do today through Etactics.

To assist customers with routing claims to the correct payer, Etactics is offering a custom calculation that will automatically change the Payer ID appropriately on the provider’s behalf if ALL criteria below are met.

• If the Policy Number is 12 numeric (No ALPHA) digits and

• If the DOS on ALL Service Lines is 12/01/2022 or later and

• If the Submitted Payer Name DOES NOT CONTAIN ‘My” or “MY’ (to exclude MyCare Claims) and

• If the Billing Provider state is OH (Loop 2010AA) 

Customers must notify Etactics that they wish to opt-in for this calculation to take effect. 

If you are interested in opting in to this Medicaid Ohio calculation (allowing Etactics to assist routing claims appropriately and avoiding Payer Rejected claims for claims sent to the wrong payer) please send an EMAIL to EDISUPPORT@ETACTICS.COM with the SUBJECT: OPT IN - Medicaid 12/01/2022. Please indicate the tax ID that will opt-in to the calculation. 

See the exhibits at the end of this notification for business case examples of how this calculation would interact with claims.

MyCare claims are not impacted by these changes and will continue to be submitted to Etactics using the current process. 

What changes for Agencies/Providers: 

New Payer IDs Effective for Dates of Service starting 12/01/2022 are listed below:

*Claims with Dates of Service PRIOR to 12/01/2022 should be sent with the existing payer IDs.

Note: These payer IDs are different from the payer IDs published by Ohio Medicaid. This has been done intentionally by Etactics to allow us greater flexibility in case the payer IDs published by Ohio Medicaid change in the future (they have already changed 3 times since Trading Partner/Clearinghouse testing has started). Rest assured, Etactics will utilize the payer IDs and file format mandated by Ohio Medicaid when the claim is sent from Etactics to Ohio Medicaid. Please use the above payer IDs when sending your claims to Etactics. 

835 ERAs delivered to Etactics

If you are currently enrolled to receive OH Medicaid ERAs (MCDOH), no additional enrollment is required to receive ERAs from the Managed Care Entities.

The only way Etactics will continue to receive ANY of your MCE/MCO ERAs is if we are currently receiving your Ohio Medicaid ERAs.

If you are currently downloading your Ohio Medicaid ERAs from the Medicaid Portal, ALL Managed Care Plan ERAs will be delivered to Ohio Medicaid for you to manually download.

If you are currently receiving your Ohio Medicaid ERAs via another vendor/trading partner, they will receive ALL of your Ohio Medicaid ERAs, including the Managed Care Entities.

In summary, Etactics is here to help you with all of your Ohio Medicaid ERA needs. If you do not currently receive Medicaid ERAs via Etactics, we strongly urge you to contact us now and enroll so that you can receive Ohio Medicaid FFS and MCE ERAs in one place (directly from Etactics).

ACTION REQUIRED by CUSTOMER

START NOW: Update your customer’s policy numbers to the 12 digit Medicaid MMIS ID for all MCEs (except Paramount).

Claims will be rejected at our clearinghouse if they contain service lines with Dates of Service both BEFORE and AFTER 12/01/2022 on the same claim, as the routing for dates before and after 12/01/2022 is not the same. Please make sure not to send claims with dates of service that span before and after 12/01/2022.

Verify your EHR or billing system can accommodate multiple insurance plans to accommodate submissions with separate payer IDs for the date of service split (ex: Caresource was 31114 prior to 12/1 DOS and Caresource and will be MCDOHCS after 12/1 DOS).

Decide if you would like to opt-in to the Etactics Medicaid Ohio calculation to assist you with new payer IDs, and contact Etactics if so. 

Decide if you would like to receive all Ohio Medicaid FFS and MCE ERAs from Etactics. If so, make sure that you receive Ohio Medicaid ERAs from Etactics today. If you do not, please contact Etactics and request to enroll for Medicaid Ohio ERAs. 

Business Cases for the Opt-In Medicaid Ohio Calculation

Exhibit 1. A claim arrives with the following information on 12/10/2022

• Payer ID = 31114

• Date of Service = 12/05/2022

• Policy Number = 123456789012

Our calculation would automatically update the payer ID on this claim from 31114 to the new Caresource MCE payer ID of MCDOHCS because it has a Medicaid ID (12 digit numeric policy number), has dates of service only after 12/01/2022, and was routed to Caresource.

Exhibit 2. A claim arrives with the following information on 12/10/2022

• Payer ID = 31114

• Date of Service = 12/05/2022

• Policy Number = 11111111111

Our calculation would take no action and the claim would be sent to Caresource (31114). This is because the policy number is 11 digits, and this is expected for a commercial Caresource policy.

Exhibit 3. A claim arrives with the following information on 12/10/2022

• Payer ID = 31114

• Date of Service = 11/01/2022

• Policy Number = 123456789012

Our calculation would take no action and the claim would be sent to Caresource (31114). Even though the policy number is a Medicaid ID with 12 numeric digits, the date of service is prior to 12/01/2022 and must be sent via the routing before the Next Generation go-live

Exhibit 4. A claim arrives with the following information on 12/10/2022

• Payer ID = 31114

• Date of Services

  • One line has a DOS of 11/01/2022

  • Another line has a DOS of 12/05/2022

• Policy Number = 123456789012

Our clearinghouse would reject this claim. Because the dates of service on this claim are before and after the go-live of 12/01/2022, it can’t be sent by either route. The claim must be split into 2 claims and sent. 

During the week of April 25th, The Ohio Department of Medicaid (ODM) formally announced that the timelines for the implementation of much of the Next Generation project (including the new claims system, Fiscal Intermediary and new MCO’s) have been delayed.

As an overall summary of these updates, ODM announced it will begin to launch its Next Generation Medicaid program beginning July 1, 2022.

The phased implementation will now occur in three stages.

Stage 1

All current Etactics customers will still be able to submit their Ohio Rise Claims through Etactics beginning on July 1, 2022 and will continue to do so once the new OMES system is also available.

On July 1, Ohio RISE will begin to provide coordination and specialized services to help children and youth with behavioral health needs who receive care across multiple systems. Recall that there could be as many as 50-60,000 children/young adults under the age of 21 who will qualify as an Ohio Rise member by the end of June 2023. This builds on the work already underway including the selection and launch of a statewide network of community-based care management entities (CME’s), the design and build of a centralized technology for the Child and Adolescent Needs and Strengths (CANS) assessment tool, transition grant funding to Care Management Entities (CMEs) and MRSS providers (Mobile Response and Stabilization Services) to launch new OhioRISE services and support provider and workforce development. From a billing and reimbursement perspective, this does mean that most all Ohio RISE services from treatment providers will be billed through Aetna beginning on this date. We at Etactics still believe that there are some unknowns as of this date as to how some of these billing functions and processes will be carried out.

Stage 2

In October 2022, Centralized Provider Credentialing will begin through the Ohio Medicaid Enterprise System (OMES) Provider Network Management (PNM) module, which is intended to 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

This is the stage that is most related to our services here at Etactics.  During the last three months of 2022 (Q4), ODM will finish implementing the Next Generation program with all seven Next Generation managed care entities plans (MCEs) beginning to provide healthcare coverage under the new program. ODM will also complete the OMES implementation including the Fiscal Intermediary (FI) which is intended to simplify and streamline the provider process for submitting claims and prior authorizations. Etactics will continue testing with ODM as a Pilot Clearinghouse with the intention of being able to submit all claims and transactions through the Fiscal Intermediary on behalf of our clients and future clients.

In preparation for this process, providers are encouraged to start collecting and utilizing the patient’s Medicaid ID numbers on claims for all current MCOs besides Paramount. When ODM implements the final changes in this stage, Medicaid ID numbers will be required on claims -- MCO policy numbers will not be accepted.

ODM states that they are committed to launching the Next Generation Medicaid correctly. The phased timeline is intended to minimize disruption to members’ care or provider support and ideally create minimal disruption to payments and reimbursements. Likewise, Etactics is dedicated to providing our clients with up-to-date information regarding the change and making the migration as smooth as possible.

In July 2018, Ohio Medicaid changed how it paid addiction treatment and mental healthcare by allowing private companies to manage Medicaid plans on behalf of the state. The state introduced it in phases over several months. Each phase included huge adjustments for claim submissions. The redesign made it harder to use manual processes since there are more payers, making it unmanageable. Behavioral health organizations had to define new workflows for how they would submit claims and correct denials.

In 2022, Ohio Medicaid announced the next award of MCO contracts with three new MCO's now coming into the state…

• Humana

• Anthem

• AmeriHealth Caritas

There will also be a new Fiscal Intermediary as well, all beginning Q4 2022.

Etactics will have connections to all of the new additions as well as the Fiscal Intermediary and Ohio Rise. We will continue to assist our customers in this next critical transition period. With over 80 Ohio Behavioral Health agencies representing over 3,000 providers/clinicians, Etactics is the leading clearinghouse in Ohio.

ODM “Next Generation” Update as of 5/2022

We wanted to take this opportunity to provide you with an update on the upcoming changes to the ODM "Next Generation" claims submission processes now going into effect on Q4 and the efforts of Etactics to best help our customers prepare for these critical changes. As of this update, Ohio Rise is still scheduled on July 1, 2022. Etactics customers will still be able to submit Ohio Rise claims to Etactics.

Etactics is currently one of the few Clearinghouses that is currently engaged with ODM as a Pilot Clearinghouse. We have passed our security and connectivity protocols and are now in the middle of actual claims testing for the new OMES system. Once Q42022 arrives, you will still be able to continue using Etactics to submit all of your Ohio Medicaid and Ohio Medicaid MCO/MCE claims, receive your remits and perform eligibility requests though Etactics. If there is anything that you currently do directly today that is independent of these functions, please let us know and we can gather additional clarification.

We plan to provide regular updates to all of our Ohio customers on this project as we continue to test and gain clarity on these new processes. From what we have understood so far, we anticipate some additional setup configurations regarding:

1. Member policy numbers. We understand that the OH Medicaid Policy Number will be used for all claims, including the MCO/MCE claims.

2. Payer ID's. There will be possible updates to some payer ID's as we await some additional specific ID's for an MCO/MCE Medicaid LOB that may be requested to be made in your EHR, but those ID's are not confirmed yet. Etactics will handle all of the other technical configurations needed to support the claims going to the new OMES and then dispersed to the respective MCO/MCE's.

3. There will also be some new and additional "SNIP" edits and Etactics is aware of those and we are also mapping any new error or rejection messages that we see coming over in testing.

Overall, ERA Remits are scheduled to come back through OMES, but Etactics as the Clearinghouse will still be able to provide those to you. We understand that the ERA's will still be an individual remit from each MCO/MCE. More will be known once full end to end testing is completed with the MCO/MCE's.

Currently we are meeting once per week with the Deloitte and ODM Project leaders. Please let me know if you have any other specific questions and will attempt to get further clarification if needed and as processes are confirmed with our testing. Unfortunately, this new process does not appear to be as simple as ODM might have thought but rest assured, we are very confident that our clients will be provided with as much advanced knowledge as soon as we have continued updates and details.

July 2021 Ohio Behavioral Health Update

There are a lot of unknowns still out there regarding the new PNM system and MCO changes. As such, we would like to share some helpful information on the new Fiscal Intermediary and its connections.

As an Ohio-based Clearinghouse, Etactics will maintain its “Trading Partner” status with Ohio Medicaid and the new PNM system. We’re also in contact with them now while waiting for next steps and testing once available.

Current members and current customers of ours will still be able to go through Etactics to submit to the Fiscal Intermediary. Some members might opt to go direct, but for those still wanting to use Etactics, we will also have that connection.

We also have connections to all of the newly awarded MCO's (Humana, Anthem, AmeriHealth Caritas) just in case you need to connect electronically with them prior to the official switch.

Buckeye Health is still in a "deferred" status. Meanwhile, the Paramounts’ challenge to the awards received dismissal.

As representatives from the Ohio Council stated recently, there is still a lot that isn’t known yet. We believe in our preparedness to help Ohio agencies in a number of ways, regardless of their claims mix. Yet, Commercial payers will still need to go through a clearinghouse.

The new Ohio Rise program and associated Aetna claims will still need confirmation on its process and Etactics can handle it for you.

Paramount Issues a Lawsuit to the State of Ohio

Paramount issued a lawsuit to the state of Ohio, which will delay the MCO awards slated to start in 2022 and the use of the new fiscal intermediary.

Regarding the key areas of telehealth, please be assured that telehealth will still be a viable option for all behavioral health groups going through Ohio Medicaid and the MCOs, but the commercial insurance plans may have their own individual rules, waivers and transition plans. Your licensing board still dictates which rules must be followed.

In their memo to licensees, the CSWMFT Board announced that licensees must immediately return to complying with telehealth rules in 4757-05-13 that require face-to-face visits, including audio-visual services for all new clients, obtain written informed consent for services for all new clients, and use HIPAA compliant technology for telehealth services for all new and existing clients.

Upon receipt of this information, the Ohio Council engaged in immediate advocacy to address the significant impact this decision has on client access to care and business operations. As a result, the CSWMFT Board held a special meeting on Saturday 6/26/21 to allow for a 90-day transition plan beginning, June 26, 2021, and ending on Friday, September 24, 2021, on these three issues.

Revalidations are still on hold pending the national public health emergency. The PHE is expected to be renewed up through the end of the year and at least for the next 90 days from 7/18/2021. Caresource, Buckeye and Paramount were all having issues around this.

Also, regarding the new PNM for central credentialing. It has been put on hold as of 7/14 with no new target dates yet announced. But the original July 26th start date is no longer applicable.

There are no other updates to the MCO awards other than that the language to rebid these awards were not included in the recent Ohio budget and to restart that Paramount did sue the state of Ohio and this may delay the start of the new MCO's and the use of the fiscal intermediary.

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