10/25/2023

Important Announcement from ODM on Claims Payment

OSMA just received the following update and announcement from Ohio Department of Medicaid (ODM) regarding current claims denial issues.

Medicaid Provider Association Notice:

Ohio Department of Medicaid (ODM) met with key stakeholder associations and their members regarding ODM’s direction to deny claims due to data misalignment between the managed care entities’ (MCE) systems and Ohio Medicaid’s Provider Network Management (PNM) system generated Provider Master File beginning on October 20.

As a result of the feedback and discussion, ODM has determined that MCEs will not be denying claims for PNM System data misalignment at this time. ODM will continue to work with the MCEs to determine a date to implement PNM's more streamlined data process to ensure minimal provider disruption upon "go live." Additionally, we continue to reinforce the use of the PNM Module as the single source of truth, encouraging providers to keep their data current in the system at all times.

What is data misalignment?  

Today providers are paid through a combination of data reported directly to MCOs and data provided to ODM. The data reported by the provider to ODM is included in the Provider Master File (PMF), which is shared with MCOs daily. When the MCOs data and the PMF data for claims processing disagree, this is referred to as “data misalignment.” The goal is to simplify the number of places providers must update their data and produce a single source of truth for processing Medicaid claims, that being the ODM data contained on the PMF. 

For provider awareness:

• ODM and MCEs will monitor claims for data misalignment between the PNM module data and provider submitted claims. MCEs will develop processes to notify providers of misalignment to ensure the PNM module is updated and aligned to claims data. 
• ODM's expectation is that Medicaid provider data in the MCEs’ systems is current and consistent with information in ODM’s system of record, the PNM System. 
• MCEs will integrate and use Medicaid provider data generated from the ODM’s system of record, the PNM System.
• MCEs must conduct daily reconciliation, 7 days per week, of Medicaid provider data using the PNM PMF.
• MCEs must not accept changes from providers into their own systems that are inconsistent with PNM system data shared through the PMF. 
• MCEs must direct providers to update their ODM record in the PNM system. 
• Provider data or information not collected in the PNM system and therefore not included on the PMF (e.g., provider capacity, telehealth availability, specialist information) may be collected from providers by the MCEs and maintained in their systems to meet provider directory requirements. 

ONGOING ACTION REQUIRED: Providers or trading partners 

1. Check that all data submitted on a claim and within the PNM module (e.g., addresses, affiliations, specialties, locations) are aligned and accurate. 
2. Access Provider Education and Training resources within the PNM 'Learning' tab for step-by-step instructions.
3. Continue to update data as changes occur. MCEs will use this information as the system of record moving forward.

For more information: 

For technical support or assistance, providers should contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 and follow the prompts for Provider Enrollment (option 2, option 2) or email IHD@medicaid.ohio.gov. Representatives are available Monday-Friday, 8 a.m.-4:30 p.m. ET. 

To learn more about the PNM module and Centralized Credentialing, providers can visit PNM and Centralized Credentialing page on the Next Generation website.