2/8 Update: Issues, Resolutions Related to ODM’s Feb. 1 Next Generation Go-Live
February 8, 2024
Since the Ohio Department of Medicaid's Feb. 1 go-live of the Next Generation managed care plans, new Electronic Data Interchange and Fiscal Intermediary, OHA has been working closely with member hospitals, ODM and the Medicaid MCOs to identify and help resolve issues. This Finance News item contains an OHA-developed issues log that will be updated to inform members of outstanding issues and resolutions. Note that this is not an all-inclusive list of issues and was created to help members track known issues as ODM does not publish an issues list (i.e., this issues log has no affiliation to ODM and was created to be an info-sharing tool). This issues log is updated as OHA members report issues and updates to OHA. The information and workarounds shared are not endorsed by OHA. Please consult internally to determine what is best for your organization.
Please continue to report issues to ODM and the managed care entities (MCEs), as appropriate, so they can track the issue through the system to identify its cause and work towards resolution through the appropriate MCEs and vendors. ODM prefers that providers utilize their Provider Integrated Helpdesk to report issues/concerns: 800-686-1516 or IHD@medicaid.ohio.gov. If you have an issue that is not identified below, have an update on a known issue, and/or require assistance, please reach out to Quyen Weaver. Updates and new issues since the last update are formatted in blue font. General updates will be posted below the issues log.
Click here to access ODM's Claim and Prior Authorization FAQ.
See this document for more information on how to attach claims within the PNM portal.
| Claims Processing Defects | ||
| Issue | Information | Status |
| FFS claims denying when coverage transitions to managed care (added 1/31) |
Claims when the patient's coverage switches from traditional Medicaid to managed Medicaid during their inpatient stay are being processed incorrectly. | Fix in process ETA: night of 5/21/24 |
| DRG rejections | DRG rejections mostly from Traditional Medicaid but an organization also reports this issue with CareSource. 4/25 update: The Ohio Medicaid Enterprise System (OMES) has relaxed the edit which was causing the valid DRG codes to be rejected. The fix was deployed April 25, 2023. Providers may resubmit any claim that was rejected due to this edit. 5/4 ODM update: Inpatient hospital claims submitted with a ‘submitted DRG’ may be denied. Deloitte/Gainwell/ODM staff are aware of the DRG validation issues on submitted DRG values. Workaround: Hospitals could try resubmitting their inpatient claims without the ‘submitted DRG’ since this value is optional and not used by ODM for claim adjudication. ODM groups all inpatient claims independently of the submitted DRG value. 1/31/24 update: DRG rejections on FFS claims have returned. |
Open |
| Invalid NPI/Provider affiliation rejections (added 3/20) |
*QX10 – RENDERING NPI IS NOT LINKED TO YOUR BILLING PROVIDER NPI. YOU NEED TO CONTACT PROVIDER ENROLLMENT AT OHIO MEDICAID TO GET THESE NPI LINKED. *PFLJWQ – E181 Member reports receiving these rejections from all Medicaid payers week of 3/12. 4/25 update: A member reports "We are seeing denials from both ODM and Anthem for invalid NPI. For ODM, we have verified that the NPI is active for the DOS in PNM and have called ODM and confirmed that there isn’t any data mismatch. No TCN as this is a payer reject. Anthem is also denying a large number of claims for invalid provider number." 5/26 update: ODM has informed trading partners of a defect that incorrectly rejected claims for reasons related to an “invalid affiliation between the Rendering and Billing providers”. These related issues were explained by ODM, using the below situations: 1. Missing Billing provider affiliation for the Rendering providers(s). 2. Invalid affiliation between Rendering and Billing providers. 3. Rendering provider and Billing provider cannot bill or be “affiliated with themselves. 4. Rendering provider is not affiliated with the Billing Provider. 11/29 update: Members have reported the following rejections for managed Medicaid claims: “code value not used in implementation” and “claim level rendering provider NPI invalid”. A member shared that they verified that the provider and affiliation information in the PNM was correct so claims should not be rejecting. For this member, it was confirmed that there was an issue with their clearinghouse's intermediary not being up-to-date, which was causing these rejections. If you are experiencing these rejections, we recommend verifying that your clearinghouse's/intermediary's systems have the most up-to-date provider information. 12/14 update: A member has shared the following resources their staff utilizes to verify provider affiliation: 1) Tips guide 2) ODM QRG – Adding an Individual Provider to a Group-Org 3) ODM QRG – Affiliations 1/31/24 update: Continued rejections for "RENDERING NPI IS NOT LINKED TO YOUR BILLING PROVIDER NPI. YOU NEED TO CONTACT PROVIDER ENROLLMENT AT OHIO MEDICAID TO GET THESE NPI LINKED.” and “Invalid affiliation between Rendering and Billing providers" even though they are in fact active with Medicaid and with that group. |
Open |
| Presumptive eligibility claims denying (added 1/17/24) |
If the patient was admitted before presumptive Medicaid begins we are billing as directed in the Medicaid Guidelines (Screenshot below). Our claims are being denied with a PR A1 denial that states Claim/SVC denied N650- Policy not in effect for Date of Loss. When we call Medicaid we are told that this is denying in error and that it is a known issue and there is no resolution date. | Open |
| Edit 217 (added 1/11/24) |
Edit 217-Member has an active restriction on enrollment is supposed to post only on Nursing Facility claims. This is a known defect and is currently being worked to fix. When the fix has been implemented, these claims will be reprocessed. | Fix in process |
| Erroneous NDC rejections (added 8/1/23) |
8/8 NDC update: ODM/Deloitte has determined that the NDC database used for validation is outdated and needs a refresh. The latest NDC code set (July 2023) is being tested and plan to be implemented in PROD by 8/29. Claims will need to be resubmitted. 8/29 update: Diagnosis code rejections on inpatient and outpatient EDI claims. Outpatient EDI claims are rejecting for CPT codes effective in 2023. Both issues will process and pay when manually keyed in PNM/MITS. 9/5 NDC update: ODM confirmed that they implemented the July 2023 First Databank NDC code set on Aug. 15th (Aug. 29th was their target implementation date). Moving forward, the NDC code set will be updated monthly. ODM indicates that the NDC rejections have been resolved and several members have reported that they are experiencing fewer NDC rejections (the rejections received now are valid). However, several members have reported that they are still experiencing NDC rejections on valid NDCs– example rejection below: Value of element LIN03 is incorrect. Expected value is from external code list – National Drug Code (240). Segment LIN is defined in the guideline at position 4930. Invalid data: XXXXX ODM has been informed of these continued NDC rejections. More updates forthcoming. 9/11 NDC update: Click here for Gainwell's NDC preferred drug search. As of Sept. 8, members still report receiving erroneous NDC rejections from MCEs while some members are not experiencing rejections. 9/25 ODM NDC update: The ODM/FI team have researched the issue and have identified the problem, FI will design and implement the change. A comms will be sent to the MCEs informing them of the change and confirming the timeline for them to follow suit to align with the change where applicable. Quadax shared they submitted a ticket with Availity– Availity indicates the rejection edit will be relaxed by Sept. 30. 10/9 NDC update: Click here to view the Quadax report of NDC claim rejections from Quadax clients between 8/16 – 9/21. 10/13 NDC rejection update: There is a SNIP-level edit requiring NDCs to be recognized which is causing managed care claim transactions to reject. ODM is in the process of relaxing the SNIP-level edit related to NDC codes so that it only validates that the NDC code submitted is the appropriate length and no longer validates the NDC because that function belongs to the crosswalk. The ETA on that fix is currently 6 weeks so latter half of November for resolution. 10/9 NDC update: Click here to view the Quadax report of NDC claim rejections from Quadax clients between 8/16 – 9/21. 11/20 ODM NDC update: ODM has been testing and exploring additional impacts to the system so that we can identify the root cause and implement a solution that addresses all impacted claims. ODM is finishing the root cause analysis to fully understand the complete issue and is engaging all key vendors for this complete solution. 12/20 update: Availity recently implemented a fix within their system that has resolved their erroneous NDC rejection issue. This fix was implemented on Dec. 7th and has improved claim acceptance rates. Availity has provided the following resubmission guidance to their clients: (1) All traditional and managed Medicaid except CareSource: Members will need to resubmit any impacted claims submitted prior to Dec. 8. (2) CareSource will resubmit impacted claims submitted between June 1 – Dec. 7. Do not resubmit these claims. *Note that ODM confirms they are still working on fixes to resolve their NDC defects so there will still be erroneous NDC rejections and denials until ODM implements their NDC fixes. No ETA. 1/22/24 ODM update: Vendors are in the process of working on developing/implementing the required changes to fix NDC issues. The remaining timeline is approximately 4 weeks to complete and implement the recommended changes. ODM confirmed that changes were made by Availity to improve the current submission success rate. |
Open |
| Inpatient claims missing capital and medical education add-on (added 8/8) |
This issue was first reported in early July. Not all IP FFS claims, but a majority of claims, are underpaid as the capital add-on and medical education add-on are missing from the total payment. Per Hospital Policy, this is a known defect. 9/25 ODM update: FI researched the examples they received regarding errors in hospital payments for the med education and capital add-ons and did identify a calculation error for some providers. They are in the process of designing a fix with the next step to discuss a timeline for implementation of this fix 10/13 update: OMES vendor has confirmed that capital and medical education add-on calculations have been corrected. The OMES vendor is gathering details on claims requiring reprocessing and will work with ODM on a schedule for reprocessing impacted claims. 10/31 ODM update: The FI vendor has identified an additional issue and are designing a fix to correct it. They are also working to identify claims that would need reprocessing and plan to begin reprocessing those claims the first week of November. 11/3 ODM update: The additional issues that were discovered by the vendor is currently in testing and on target to be implemented by November 10. Reprocessing will begin post implementation of the fix and will be spread over several weeks due to the volume of impacted claims. Target date to complete is December 15th. 11/20 ODM update: There are two fixes that have been deployed but there is a third that won’t be ready to implement until 11/22 at the earliest and the FI vendor will then reprocess all claims impacted. 1/11/24 update: This is still an outstanding issue. The Dec. 15th target fix data was not met. OHA waiting for updates from ODM. 1/22/24 update: ODM is working closely with their vendor to discuss additional changes that are needed to address this issue as the vendor continues its testing. |
Open |
| Misdirected/Missing MCE 835s (added 8/8) |
Buckeye: Buckeye 835s have not been delivered to trading partners since February 1. ODM is working with Buckeye to establish a timeline for creating and distributing the 835s to trading partners. That timeline will be communicated once available. 4/7 update: Buckeye identified an issue where 835 files from Buckeye were not being received by OMES; therefore 835 files sent between 2/17/23 – 3/16/23 may be reprocessed which could cause duplication. Please make staff aware of this possibility to ensure the file is not posted a second time. If you have any questions, please reach out to Buckeye Provider Services at 866-296-8731. 4/25 update: Starting April 21, Buckeye will send 835 files for the dates of Feb. 1 – March 20 to the EDI. These files are expected to be fully distributed to trading partners by April 28. Please note the 835 files for the dates of Feb. 1 – March 20 have already been distributed via Availity to providers who utilize a trading partner. Providers may choose to ignore these files from Buckeye if they are not needed to reconcile claims. All future 835 files from Buckeye will be sent to trading partners via the EDI, the single repository for all 835 files. —— Aetna OhioRISE: Aetna has identified an issue where OhioRISE 835s have not been delivered to trading partners. Aetna is working to resolve this issue, and 835s are expected to be sent to trading partners via the Ohio Medicaid Enterprise System (OMES) beginning March 29. Providers can access remittance advice (RA) via the Aetna Availity provider portal until this issue is resolved. Providers should log into https://apps.availity.com/availity/web/public.elegant.login to access a PDF copy of the RA. The RAs are available through the claim status inquiry tool. —— ODM update: ODM is aware that several of our plans had not been updating the database that provides the provider – trading partner relationship for the delivery of the 835 ERA. Therefore the 835 ERA was still being directed to the trading partner the provider had designated prior to go-live on Feb 1, 2023. The plans are correcting this issue. ODM provided all of the plans with a current table on Aug. 8. All 835s moving forward should be delivered by the currently designated trading partner. 1) An issue with the Availity system caused misdirection of MCE 835s from Anthem, Buckeye, Molina, Humana, and CareSource. Potentially ~1500 providers may have been impacted by this issue. ODM is actively working on a fix for this issue. 9/25 ODM update: The MCEs/vendor implemented a fix on August 2 and delivered historical 835s impacted by this issue to the correct trading partners. 2) A number of CareSource 835s failed compliance (very low volume). The issue was fixed on 7/24 and regenerated files were sent on 7/26. 9/25 ODM update: CareSource fixed this issue on July 24 and delivered the final batch of regenerated 835 files to respective trading partners on August 16. 3) AmeriHealth sent misdirected 835s due to a timing issue caused by their virtual credit card payment process. The fix is targeted to be implemented by Sept. 9/25 ODM update: The targeted fix for this issue is later this month (Sept.). 4) 9/11 update: ODM has confirmed failures related to UHC's 835 generation and distribution. No ETA. 1/11 update: MCE 835s are missing intermittently. Per some MCEs, the 835s are sent to ODM but the FI cannot locate the 835 file. |
Open |
| FFS PDF remits missing claims (added 9/21) |
ODM recognizes that the PDF remittance advices do not always include applicable claim ICNs even though there are recoupment amounts associated with claims. We are currently working with our system vendor to have them include applicable FI ICNs when we takeback claim adjustments as recoupments. This occurs as a result of timing. In some instances, the reversal claims cannot be taken back in the same week they are created. Once the amount can be taken it is deemed as a recoupment instead of a reversal. Again, once this change is implemented, the FI ICNs will show on the PDF remittance advice. | Open |
| $0 remittances (added 7/17) |
When Medicaid pays claims but uses the payments to offset overpaid claims and the total check amount is $0. This is part of the 835 issue where remittances are not being received. With no deposit record we have no idea the volume or impacted checks associated with this issue and request a list of all check numbers (including $0) to be supplied to providers for reconciliation on our end. | Open |
| Professional 835s missing date of service (added 6/30) |
Professional 835 files are missing dates of service. | Open |
| Discrepancies in offset amounts on PDF remits and payments (Traditional Medicaid) (added 6/23) |
We have been downloading remits for traditional MCD from the site and are posting manually. We are seeing discrepancies in the offset amts on our checks and cannot reconcile it to what our payment should be. We placed a ticket with Gainwell and the rep stated it was going to be several weeks before someone would get back to us. | Open |
| Venipuncture rejection Operating physician rejections |
We are having an issue with our Ohio Medicaid claims. It appears there was a 277 edit created for claims submitted after 2/1/2023 and they are not allowing the claims in their system. The edit is – – ACK,RETURND AS UNPRCESSBLE CLM- CLM,ENCNTER BEEN REJECTD AND NOT ENTERD INTO ADJUDICATION SYS.:ENTITY'S NAME, ADDRESS, PHONE AND ID NUMBER.:OPERATING PHYSICIAN 3/20 update from member: "We are receiving numerous payer rejections for Traditional Medicaid. The rejection reason returns "Entity s name, address, phone and id number invalid" however after reaching out to our clearing house (Quadax) they advised it was because Medicaid is now requiring an "operating physician" when a venipuncture is billed on a facility claim." 3/28 update: Members report adding the attending as the operating to get the claim out of the clearinghouse as a workaround. 10/20 update: CPT 36416 (venipuncture) is being payer rejected stating an operating physician is required. 11/28 update: Workaround – Members have confirmed that adding the attending provider to the operating provider field resolves these rejections. Rejection reported: Rejection: Loop 2310B is missing. It is required when at least one service line on a claim has a procedure code SV202-02 in range 10000?69990 (SV202-01 = HC). |
Open |
| CO45 issue on DRG claims (added 1/15/24) |
FFS inpatient claims processing with no payment with a CO45. ODM affirms this is a known issue with no ETA on resolution. | Open |
| Permedion claim rebills (added 4/13) |
We have rebilled some Permedion claims and have not been able to locate these claims on MITS. Reps are also unable to locate. Per an ODM agent, ODM is aware providers cannot see the claims on MITS and this is a known issue since they went live with the new PNM. The Medicaid reps have been told that 2/21/23 is the date that we will be able to see claims on MITS but that is not the case. 5/26 update: See this document for more information on how to rebill Permedion claims. 6/16 issue: Our issue is, we followed the workflow and attached the documentation per the supplied document ( claims attachment on PNM) but the ICN that was provided by our manual payment does not appear to be a valid ICN and does not pull any claims within the PNM portal. We are unable to view any claims on PNM directly and are therefore unable to see if the records were successfully attached. The claim attachment was submitted on 5/22/2023 and to date this claim has not posted any additional adjudication. We received this ICN from the manual payment as well as from the 277 response. 9/25 update: Permedion has confirmed that timely filing edits will be waived but documentation confirming this has yet to be provided. 12/15/23 update: ODM affirms they will waive timely filing issues, however, they have not issued an official announcement. 1/15/24: Permedion continues to conduct utilization reviews and medical record requests, however, recoupments should be on pause. Notify Quyen Weaver if your organization is experiencing actual recoupments from Permedion. 2/8/24: ODM has confirmed that Permedion recoupments that occurred in November are valid recoupments, however, that was not their intent. There should not be any Permedion initiated recoupments after Nov. 2023. OHA has requested that ODM reverse the Permedion recoupments until a systems fix is implemented to enable providers to resubmit impacted claims. |
Open |
| Medicare crossover claims paying primary (added 12/4) |
Medicare crossovers are finally processing but Medicaid is paying as primary instead of secondary. A member is working with Gainwell Technologies on a process to rectify these overpayments. A solution will be shared once Gainwell Technologies identifies their preferred process. 12/14 update: Gainwell FI has verified this is a configuration issue. The Medicare remit code 253 was causing claims to process as Medicaid primary for some reason. Their configuration team is working on getting this corrected & there will be projects opened to reprocess the affected claims. To help prioritize this fix, Gainwell has asked for a list of impacted providers. If your organization is experiencing this issue, please notify Quyen. |
Open |
| Medicare crossover with duplicate Medicaid payment (added 7/17) |
Medicare cross over to Medicaid traditional resulting in Medicaid payment as secondary when patient is enrolled in a Medicaid HMO – thus both Medicaid & Medicaid HMO have paid. There is no claim in our EDI system to cancel and the claim is not found on the PNM portal with Medicaid to void. Thus we have no way of notifying Medicaid that they need to recoup. | Open |
| Missing Medicare crossover claims (added 4/11) |
Medicaid crossover claims are not showing on the PNM/MITS portal after 2/1/23. 4/13 update: A member hospital is tracking claims back to October 2022 that are not being received. 4/19 update: A member reports, "The issue is with our Medicaid secondary claims that Medicare is forwarding on. Our followup team is calling on them due to no payment and Medicaid states they have not received the claims from Medicare, yet Medicare tells us they have forwarded them. Today, our followup team was told, by Medicaid, that this is a known issue and there has been no resolution to the problem at this time." 9/11 update: ODM believes that they have been processing Medicare crossovers for months. However, crossovers are being rejected for provider-affiliation and unknown NPI edits. Per ODM, providers must correct the provider affiliation and NPI issues as ODM believes that there is not a true systems issue related to Medicare crossovers. ODM also mentioned that they have asked Medicare if they could submit smaller batches so a transaction set would contain fewer claims, as just one claim within a transaction set that rejects/fails the provider affiliation front-end edits causes the entire transaction to fail from processing. However, members are still reporting issues with crossovers. As a workaround, members report submitting crossovers manually through their clearinghouse which have been successful. 9/25 ODM update: If Medicare has paid their portion of a claim but you do not receive ODM payment in the following ninety days, you must directly submit a corresponding crossover claim to ODM. You have the option to submit the crossover claim through the Provider Network Management (PNM) module via a link to Medicaid Information Technology System (MITS) or through a trading partner to the Electronic Data Interchange (EDI). This direction is aligned with the Ohio Administrative Code 5610-1-05, “Medicaid coordination of benefits with the Medicare program (Title XVIII).” 10/25 update: Claims that did not cross-over after Medicare to FFS or did and then we got a denial for other payer info missing, we resubmitted them and now we have some of them coming back processing as secondary payer but paying more than the co-ins and or deduct. There appears to be an issue with these calculations. |
Open |
| Medicaid billed as secondary with primary payment information (added 7/17) |
Medicaid/Gainwell EOB reflects the primary payment information but Medicaid still processing as primary up to their allowed amount – we are told that COB files were corrupt when claim processed. Unable to pull the claim up on PNM portal to request adjustment/correction. | Open |
| Secondary claims posting CO96 with MA04 (added 11/22) |
We are starting to see ODM use CO96 with MA04 (Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.) When processing secondary claims instead of the normal OA23 to indicate that primary paid more than allowed. We’ve called them and they have confirmed that the primary payment information was there and associated with the claim. (So frustrating that we have to call since we still cannot see claims in PNM.) | Open |
| Incorrect billing for Medicaid secondary claims (added 3/27) |
Traditional MCD is being billed as a secondary payer on a claim where a Medicare HMO is primary. The denial is for other insurance coverage. Called and was instructed by rep and then supervisor that the claim needs to be submitted with either Traditional Medicare Part A or B and not the HMO. Seems to be affecting all claims with submission dated of 2/1 forward regardless of the DOS. It was verified the patient truly has the HMO coverage. Also verified prior claims of service for same patients with same primary/secondary coverage submission and those claims processed and paid accurately. 5/4 ODM Update: If a member has Medicare coverage primary, then the claim filing indicator must be MA (Part A), MB (Part B), or 16 (Part C). If a hospital puts any other claim filing indicator (such as BL), FI will not post a COB edit stating that member has COB on file but no COB was reported. It is important that hospitals use the correct filing indicator when reporting COB on Medicaid secondary claims. Likewise, filing indicator CI should be reported when a member has Third Party Liability (TPL coverage that is not Medicare). ODM and GW are working collaboratively to review the proposed solution this week. |
Open |
| Issues potentially related to former 10/20/23 deadline to update provider info in PNM (added 10/27) |
1) We have quite a few Medicaid rejections for NPI since the 10/20/23 change. Some our credentialing specialist has found obvious issues that need to be addressed in PNM and corrected them. Others, there are no obvious issues that we can see. We had a few that PNM was not updated until 10/19/23-10/25/23 so we resubmitted some of claims thinking that it was just the delay. However, they are still rejecting the claims. 2) We too are receiving a number of denials for FFS Medicaid since the change. But they are not for the NPI. We are seeing a denial reason of A1 on the remittance and there is not any explanation with the denial. Our hospital remit this week only a few claims paid. I went into our PNM system again and I do not think this has anything to do with a provider not being added. 3) Yes, all of our Medicaid claims for our Provider Group are rejecting. We called ODM and they said our Group number was inactivated but when I go into PNM the last update says Approved/Completed. I sent an email to ODM Helpdesk and waiting on a response. Funny thing is if you enter a claim directly into MITS it processes so you know it has to be the ‘front door’. |
Open |
| Credentialing with incorrect effective dates | ODM is approving providers with incorrect effective dates, which stops our ability to affiliate the provider with organization which delays claim submission. ODM is aware and there is a workaround in place. A weekly report is submitted to ODM to correct the effective dates. Once the dates are correct, we are able to complete the affiliation process and release claims. |
Open |
| Credentialing status (added 3/20) |
Credentialing issues with many providers not showing active when they should be. A member shared this response from an MCO: "this is a known issue with ODM and MCOs. Everyone is working on a fix to correct the lag-time in the file transfers and how the files get processed." |
Fix in process |
| OP LARC claims denying (added 12/4) |
Medicaid is denying the outpatient LARC claim when provided during an inpatient delivery stay. The policy that provides separate reimbursement for these LARC claims has not changed. | Open |
| ER denial for no auth (added 9/21) |
ER visit deny for no auth #, when I called Medicaid they stated they would not reprocess it because we should have got an auth. | Open |
| FFS claim denials for CARC 4- 4-Px incons w/ modif/reqd modif missng (added 9/21) |
Claims with the CARC 4 issue – 4-Px incons w/ modif/reqd modif missng. All have a claim number that has an E – example 12345E0012345 will be sent for reprocessing once ODM fixes the issue. ODM cannot state what happened or what caused the glitch in their system. ODM system will find the CARC 4 claims that have an E in the claim number to reprocess them. We do not need to resubmit them, nor do they have a spreadsheet for us to send them on. |
Open |
| Inpatient transfer claims paying DRG (added 8/29) |
Inpatient transfer claims are paying the full DRG rate instead of the transfer rate. | Open |
| PR45 and OA18 (added 8/11) |
Denial codes PR45 and OA18: Responses from Medicaid was there other Medicaid coverage or call into verify the true issue for the claim. | Open |
| Physical therapy denials/rejects (added 8/11) |
Denial/rejects for Physical Therapy authorizations. | Open |
| PLB (added 8/11) |
Unable to gather details for PLB and the PNM integrated help desk has not been helpful. |
Open |
| FFS drug details denying (added 9/11) |
Two lines for same drug code but with different NDCs are denying. Denial is CO16/N572. In this case, the same claim with JW modifiers show RMC COA1/N823. | Open |
| CO-B7 denials (added 9/11) |
For the month of August, we had 591 accounts that denied for CO-B7, stating “provider was not certified/eligible to be paid for this procedure/service on this date of service.” Our team has called ODM for clarification on this denial and the rep stated, “they are aware of this denial, and they have to send the claims back to be tracked. When the issue is resolved, the claims will be reprocessed. Reps have explained there is no time frame for when this will be resolved.” One member shared that their organization looked into the provider on each impacted claim and corrected the issue within the PNM system which resolved the issue for them. There was discussion that this could be related to another issue, which was fixed so it members may want to resubmit claims. 9/26 update: Members reported experiencing this issue on hospital and professional claims. I was able to get feedback from my physician billing team about the B7 issue that was called out on the meeting today. I am being told that they recently started getting the denials from ODM. They are trying to figure out a pattern on them as the B7 traditionally is a credentialing issue (provider not active on DOS) on the physician claims. They did notice that some might be diagnosis related and possibly SLMB coverage for the patient. They are continuing to look into the issue to find out more information. 10/17 update: Members report seeing denials from Traditional Medicaid for CARC B7 (THIS PROVIDER WAS NOT CERTIFIED/ELIGIBLE TO BE PAID FOR THIS PROCEDURE/SERVICE ON THIS DATE OF SERVICE) and all of the recipients are either SLMB, Q1/Q2 or some other Medicaid status that is a premium assist only (i.e., no Medicaid coverage). Those programs only cover the Medicare part B premium so it is appropriate for those claims to deny. There is confusion with B7 posting on these claims as it makes it seem like there is an issue with the provider contract, when in reality there is an issue with the patient's Medicaid eligibility. OHA has asked ODM to reconsider B7 for these eligibility denials and select a remark code that is truly indicative of the denial reason. |
Open |
| Clinical diagnostic claims (added 8/10) |
ODM update: Ohio Department of Medicaid (ODM) is aware that some claims for clinical diagnostic laboratory services are currently not being paid because system edit 103 has determined that the procedure reported on a detail line is "not an approved service for provider". This problem is occurring because the Fiscal Intermediary (FI) is attempting to verify the Clinical Laboratory Improvement Amendments (CLIA) certification only of the rendering provider (e.g., individual practitioner) and not of the billing provider (e.g., professional medical group). Claims with detail lines for clinical diagnostic laboratory services that are affected by edit 103 were in 'pending' status but have been released for processing, at which point payment for the pended details will be paid or denied. ODM is working with our vendor on a solution to this issue. We will provide updates as they become available. Please direct any questions about this matter to NONINSTITUTIONAL_POLICY@medicaid.ohio.gov |
Fix in process |
| Outstanding FFS balance due to MITS/FI conversion (added 8/1) |
Members are seeing outstanding FFS balances. The large balance stems from a conversion issue with balances showing as open when the ARs were converted from MITS to Gainwell FI. At that time, the 2nd and 3rd HFF assessments were open in MITS because they were due after the 2/1 date. Hospital Policy has opened a ticket to have the FI clean up open balances related to HHF and HCAP for all hospitals. 8/24 update: The permanent fix for this issue is scheduled to go in next Tuesday (8/29) evening. The closure of the ARs that’s incorrectly showing an open status in the FI system were closed Wednesday (8/23) evening. 9/11 update: Members report experiencing $0 payments as recoupments for these erroneous outstanding AR balances. ODM is aware of this issue and is investigating. 9/29 ODM update: FI is pulling a report of provider account balances that may exist for providers who submitted claims to MITS, then attempted to reverse those claims in MITS after the claim and payment were transferred to FI for further management. It's a fairly complicated report so the work is still in process. Once completed, FI and ODM will review the report before sharing the results 10/13 update: Per ODM, the account balance issues from MITS conversion have been resolved. 10/31 ODM update: The FI vendor have determined there are receivables that the providers see as having been “double paid.” For example, an AR of $1000 was taken twice for a total of $2000 and the extra $1000 has still not been returned. The technical team is working on identifying these instances and will provide a report to ODM on the results. 11/20 ODM update: The technical team is still researching to figure out how this is happening and if it is related to how the AR was converted or something that was done to the AR after the AR was loaded into FI. Additionally, the AR balances have been difficult to associate with a specific claim or transaction. ODM has instructed FI vendor to add the specific identifiers to the 835 to facilitate easier referencing for all AR balances. |
Open |
| Physical therapy claim denials (added 6/29) |
Physical Therapy claims are still denying for no authorization for Ohio Medicaid FFS. Started in February after the change over. We received the first denial on 2/16/23. The denial code is CO 15 remark code M62. We have rebilled and some paid and some still denied for lack of authorization. | Open |
| Traditional Medicaid split claim (added 6/16) |
A large dollar claim (over $1 million in charges) was split by the FI. Unsure if this is intentional or a defect. If intentional, unsure of why the claim was split, criteria for splitting claim for payment, etc. | Open |
| MyCare Opt-Out, Medicaid Only Benefits Claim Rejections (added 6/2) |
Claims for a patient who has opted out of their MyCare plan and only receiving Medicaid benefits are rejected by all MCOs when the claim is submitted with the new Payer Id. It appears that the system is requiring the old Payer ID since it is a MyCare patient, but since the patient opted out of MyCare, it should be accepted with the new Payer ID. | Open |
| Medicaid eligibility discrepancies (added 5/10) |
There are discrepancies in a Medicaid member's MCO assignment, which impacts eligibility. For example, ODM states a member is active with Buckeye, but Buckeye states the member is not eligible. For members who are dropping off of Medicaid due to redetermination as of May 1, and have applied for Marketplace coverage, the individual is showing as eligible for both a Medicaid plan and Marketplace plan in April. 5/26 update: MCOs have indicated that the eligibility files received from ODM are corrupt and contain incorrect member termination dates. ODM is aware of this issue. 7/13 ODM update: A fix has been tested with the MCO’s that went into production 7/11. We’re expecting that this corrects the issues that are impacting plan denials. 8/21 update: The fix was unsuccessfully. ODM continues to meet with the MCOs and its vendors on a fix. 8/24 ODM update: The work on the 834 continues but it has been improved within the last couple of months with Gainwell promoting a number of fixes in July. While the 834 work continues ODM has issued guidance to the MCO’s to cease termination (including retro terms) of member enrollment based on the daily 834C file. The plans have been instructed to term members based on the monthly 834F files. Further, Gainwell has been providing the plans with monthly discrepancy reports for plans to reconcile enrollments. Based on these changes the provider community should not be seeing the amount of erroneous takebacks they have been. |
Open |
| IP surgeries which require PA (added 5/4) |
ODM shared: Gainwell and ODM staff are working to resolve an issue with hospital prior authorizations tied to ICD-10 inpatient procedure codes. There are some inpatient procedures which require PA but the FI system needs configuration work to process Inpatient Prior Authorizations for ICD-10 procedure codes. It is currently configured to validate revenue codes or CPT/HCPCS codes on Prior Authorizations. | Open |
| Dialysis code 90999 (added 5/4) |
ODM shared: There is an open ticket for improper denials (edit 152 – Provider Type Does Not Match Benefits and edit 214 – Bill Type Does Not Match Benefit). This service is a covered benefit for outpatient hospitals. | Open |
| IP psych claims paying w/o pre-cert (added 5/4) |
ODM shared: There is an open ticket for psychiatric inpatient claims paying without an approved psychiatric pre-certification on file. All psychiatric admissions require pre-certification unless the admitting diagnosis is medical, Medicaid eligibility is pending at the time of admission, or Medicare is primary for the member. | Open |
| IMD claims paying for restricted age groups (added 5/4) |
ODM shared: There is an open ticket for Institutions of Mental Disease (IMD) claims paying for restricted age groups. Per 42 C.F.R. 438.6(e), Medicaid (FFS) cannot reimburse IMD stays for persons between 21 & 65 years of age. | Open |
| Claim rejections (added 4/27) |
We are seeing a large number of claims rejecting with the error message below. These claims are rejecting before they get into the Medicaid system so there are no ICN numbers associated with the rejections. Status code 35 – Claim encounter not found. Category code A4 – Acknowledgement/Not found-claim can not be found in the adjudication system. We are also seeing claims that we manually keyed into MITS as well as claims that we corrected in MITS, are now suspending for the reasons below. UNABLE TO DETERMINE PRICING METHOD FOR DETAIL – These two claims are showing in paid status now, but they paid zero due to this error. SYSTEM ERROR – THE EAPG CODE DOES NOT HAVE A WEIGHT ON FILE FOR THE CLAIM DETAIL FROM DATE OF Service – Provider contracted/negotiated rate expired or not on file. |
Open |
| No claim on file (added 4/13) |
We are seeing that claims are delayed in being loaded to the payers' portals (all payers). Before Next Gen I was able to see claims within 24-48 hours. Currently I have claims that have been released for > 2 weeks not showing on portals. Impacting FFS and Managed Medicaid’s. 5/26 update: Managed Medicaid EDI claims are not always making it to the MCO. Claims are getting lost in the FI and not being routed appropriately. Managed Medicaid ARs have increased as a result of this missing claims issue. |
Open |
| Non-digit in ICN (added 3/27) |
Any TCN that has a letter in it, we cannot look at the claim in the system, for example: 00000E0000000 | Open |
| Claim processing under incorrect plan (added 3/27) |
Claims for a January date of service are being processed under the new managed care plan that was not in effect until Feb and being denied because no authorization was in place. So, a patient who had traditional Medicaid in effect until 1/31/2023, the claim was submitted to ODM on 2/10/2023, but is being processed under her Humana, that is not in effect until 2/1/2023. | Open |
| No or less than expected payments (added 03/20/23) |
Members report not receiving payments for Traditional Medicaid claims or receiving substantially less than expected payments for February dates of service and forward. Members also report similar payment issues with MCOs. OHA continues to advocate for hospitals to be eligible for bridge funding while we navigate these claims processing challenges. 3/20 update: Per a March 17 ODM communication to trading partners, ODM states "ODM is taking several additional steps to improve the FFS payment rate. Edits within the Fiscal Intermediary (FI) are being relaxed to ensure claims accepted by the EDI system are not rejected by the FI system. Claims previously rejected by the FI due to edits that are being relaxed will be reprocessed automatically and do not need to be resubmitted. For trading partners with lower acceptance rates, ODM is examining errors to identify common causes and provide specific guidance to improve the successful transmission of claims. ODM is also carefully monitoring suspensions, denials, and payment rates to ensure consistency with historic standards." As ODM relaxes their system requirements to process more claims, please inform OHA of successes in claims processing and payments as well as continued claims processing rejections and issues. |
Open |
| Payer status code rejections (added 3/20) |
Claims rejections for PAYER STATUS CODE : E014 024 : Other Unlisted Reason. An organization reports receiving this rejection from all Medicaid payers. | Open |
| 277CAs | 3/14 ODM Email: The Ohio Department of Medicaid (ODM) has identified issues that can occur when trading partners generate 277CAs (Claims Acknowledgement) for fee-for-service (FFS) claims. While the issues are being resolved with urgency, some trading partners may temporarily experience missing 277CA documents, or missing claims within 277CA documents. These missing claims could appear as “Submitted to OMES” within the trading partner’s systems/utilities. In addition, ODM is addressing an issue of FFS claims being rejected in the 277CA. FFS claims rejected in the 277CA will not be loaded to the Fiscal Intermediary (FI) adjudication system and will return a “Claim not found” if inquired by trading partners. FFS claims rejected in the 277CA will not be reported on an 835. 4/4 update: ODM March 30 sent the following message to trading partners: "ODM has identified errors caused by the STC segments being stripped out of the 277CA. This results in trading partners receiving a 277CA that does not account for all of the claims in the 837 file. A patch was deployed on March 27, to resolve this issue. This patch addresses the following: • 277CA Generation issue when rejecting at the Billing Provider level. • Invalid Element DTP03 (Date Time Period) is missing. ODM will monitor the processing results of ongoing 277CAs for five days to determine the efficacy of the fix. After that monitoring period, ODM will develop a plan to handle previous volumes of missing or incorrect 277CAs and provide an update on the monitoring results in a follow-up communication to trading partners next week." Per Quadax, "277CAs (claim acknowledgements/responses) from 03/29 and after are now being returned within the promised 24-hour processing timeframe. Quadax has also confirmed the various 277CA response files were received for all files process from 3/27 and 3/28, as well. However, Quadax has still not received historical 277CAs for many files processed prior to 3/27. Quadax continues to be in contact with ODM, who has confirmed they are still working on resolving the issues with the backlog of missing response files." 4/25 update from ODM: Between Feb. 1 and March 28, the OMES experienced an issue in the FI module that caused some trading partners to receive incomplete 277CA files for FFS claims submissions. To remedy this issue, between April 26 and April 28, trading partners will receive a 277CA reconciliation report that includes the results of the 277CA stage validation outcomes for the claim files submitted Feb. 1 – March 28. These results will be sent to trading partners in a simplified Excel file format. Results will be provided as a one-time activity and will be available for 14 days after being delivered to your EDI OUTBOUND folder. A PDF file with instructions on how to read the results will accompany the 277CA report. Trading partners can use the 277CA reconciliation report to reconcile previously submitted claims and resubmit all rejected claims. 5/8 update from Quadax: Quadax recently received a report listing ODM’s “missing” claims that it confirmed were never received in its system due to previous issues with its “One Front Door” implementation. In a previous notice from ODM that Quadax shared, it identified a few options to allow for these missing claims to be resubmitted for payment, also resulting in the receipt of the missing 277CA (claim file responses). After carefully reviewing the available options given by ODM and reviewing the report, Quadax has chosen Option 1: “Resubmit all impacted claims. A 277CA will be returned for all rejected and accepted claims in the resubmitted files. Accepted claims will be loaded into the claims system for processing. If a resubmitted claim is found to have been previously submitted and paid, it will appear on the 835 as denied as a duplicate submitted claim. If this option is used, we encourage trading partners to communicate to their providers about the duplicate claims.” This means that Quadax will resubmit the affected claim files for the days containing missing claims identified by ODM’s report. More specifically, all claim files processed to ODM through the “One Front Door” have been re-processed for the following dates: 2/20~2/26, 2/28, 3/1, 3/2, 3/21, 4/1, 4/8, 4/22, and 4/25. As stated in the notice from ODM, claims which were previously processed and paid will appear as duplicate claim denials on 835s and can be disregarded. |
Fix in process |
| 999 rejections | 999 Rejections- Health systems and clearinghouses were being advised the rejections are due to an affiliation issue/provider not correctly affiliated. Although some rejections were related to this issue, there was also an issue with the EDI and a failure to properly pull the affiliation information into the EDI system. This communication was confusing to health systems and clearinghouses. ODM is aware of the issue and the EDI is working on the fixes. |
Fix in process |
| MCE-Specific Issues | ||
| Incorrect COB updates resulting in takebacks | Due to a PNM issue, eligibility files with incorrect COB information are sent to the MCEs thus resulting in erroneous takebacks. Notify Quyen Weaver of these occurrences by plan, if possible. | Open |
| Anthem-missing 835s (added 1/15/24) |
Members report missing 835s from Anthem. When asked about these missing files, Anthem indicates the files have been sent to ODM so the issue is with ODM's system. Anthem does not post 835s to their portal while all other MCEs post 835s to their portal. 1/17/24 update: Anthem has recently identified an issue with 835s where a missing field of information related to patient liability is causing rejections of the files when sent to ODM’s FI. All claims associated with a rejected 835 would be affected even if only one claim contains the error, since the 835 is submitted at the check level. The error was identified related to a Anthem system release that occurred on 11/11/23. If providers are inquiring about a missing 835 on or after 11/11/23, Anthem is working to have the 835s corrected and resubmitted to the State’s FI on or before 1/31/24. If providers/trading partners are not able to access their missing 835s on or after 2/1/2024, please submit a research ticket thru ODM at EDIHelpDesk@medicaid.ohio.gov so that Anthem can further research the issue. |
Fix in process |
| Aetna/OhioRISE-Missing claims (added 4/7) |
With the OhioRISE claims submitted to payer ID # 45221, we are not seeing any rejections w/ Change Health Care, but receiving the status code – E0 35. This seems to be isolated to Hospital claims, but we have called and Aetna states no claim received and no rejection in their system; however, the clearinghouse acknowledges claim was sent to payer. | Open |
| Anthem-Member ID data mismatch | Anthem is still reverting back to old Paramount IDs in their RTE responses so they are not returning the MMIS. | Open |
| Buckeye-Duplicate files (added 6/23) |
Buckeye is producing the same [835] files through 2 separate payor ids. That payor ID is not exclusive to these duplicate remittances so it is not possible to simply eliminate one payor id. | Open |
| Buckeye and Molina-Credentialing | Buckeye and Molina are not using the PNM system for credentialing—this has been an issue since 10/2022. 3/16 Molina: Molina has engaged with Highland District Hospital directly. Molina is using the PNM for credentialing purposes for the Medicaid and MyCare Ohio lines of business. Molina also requires a Provider Information Update Form (PIF) for a number of reasons. The PIF contains the Medicaid Addendum Attachment A, which ODM still requires at this time. The PIF includes other relevant organizational and individual demographic information which enables us to confirm the provider's ODM enrollment and get the provider loaded into our systems, including capturing some details not currently included in the PNM PMF files. Molina credentials the provider for our other lines of business, so the credentialing information "Section N" is also needed. |
Open |
| CareSource-Invalid POS denials | With CareSource, we are getting invalid place of service denials on our radiation/oncology claims that are dates of service in January and billed in February. When we told our rep about it, she said that it is a global issue and they have an open ticket to fix this issue and is in the testing phase at this time. | Fix in process |
| UHCCP-Unable to submit dental claims (added 8/24) |
Since 2/1, we have no way to submit our dental claims from our professional billing system. We have been working with our trading partner on submitting our claims to UHCCP, as the payer had indicated that they had established a way to transmit them. Our first set of test claims for this process has rejected. There has been no update on establishing a way to transmit our dental claims to any other Medicaid MCO and we are not able to drop them to paper. 12/11 update from UHCCP- UHCCP’s delegated vendor for dental is DentaQuest (DQ), DQ administers and pays all claims not UHCCP. Are you submitting claims to DQ and not UHCCP? Who is doing the testing who rejected? More information required to respond to: Who is the Payor you are referring to in this case? [Send information to Quyen Weaver to relay to UHCCP.] |
Open |
| Medical drug auths routing to Gainwell (added 3/20) |
A few of the managed Medicaid payors portals members use to obtain medical authorization for physician administered medication are directing to Gainwell. From our understanding, Gainwell is for pharmacy authorization not medical authorization. | Open |
| Systems Issues/Limitations/Program Frustrations | ||
| PNM critical error (added 1/15/24) |
Since go-live members report seeing a "critical error" message when using the PNM. Impacts ability to attach documents and manually submit claims. This error has been sporadic but has become more frequent over the past few months. | Open |
| 6653 process not working (added 1/15/24) |
ODM's 6653 process is not working. | Open |
| Claims not viewable in PNM (per ODM, this is by design) | 3/20 update: Providers wanting to view or edit a claim, must use the same system that was used for the original submission. These systems include MCE portals, MITS page accessed via the PNM module, or through an authorized trading partner utilizing the new EDI portal. For example: if a provider submits a claim via MCE portal, the provider must then use the MCE portal to view or edit their claim. Claims submitted via trading partners are not viewable within the PNM module; however, providers can work with their trading partner to view a claim status. ODM stated EDI claims will be viewable within the PNM when that module’s functionality is fully implemented, but an ETA has not been announced. 1/1/2024 update: ODM has not provided an ETA for this system enhancement. |
Fix in process (when PNM full functionality is implemented) |
| Unable to change provider's Primary Specialty | Unable to change a provider's Primary Specialty in PNM. We need this capability to make changes due to additional training, change of specialty, etc. In addition, if a Primary Specialty is incorrect, updates need to be made to correct the record. ODM is checking into the issue. |
Open |
| PNM limitations | The PNM portal only allows for 1 administrator to be registered with very little delegation options of tasks. For all new provides to process credentialing, this task falls strictly on the admin. For a re-evaluation, there is an option to delegate to another user enrolled (staff member). This is very time consuming for us (can’t imagine the burden on larger facilities). ODM only allows one administrator, however, they transfer that administrator role simply by employees calling and requesting access. Although they do have a process in place to prevent this, it is not always adhered to by their customer service department. Unable to assign agent access for individual providers by group ID. Still required to assign access to agents for each provider under the group ID. Requesting either the option of having more than 1 administrator or delegation privileges to reduce administrative burden. |
Provider request to ODM |
| Cannot look up provider by NPI in PNM (added 8/29) |
Cannot look up providers by NPI in the directory. Informed by PNM help desk that practitioners have to be associated with us before we can look anything up about them. | Open |
| SPBM audits | Gainwell is asking for weekly audits of up to 45 per week from organizations. This seems excessive and not in line with other payors. The audit requests can take 20 or more hours a week to complete and can be several hundred pages. Organizations report not seeing a single audit report come out of these audit requests or any other feedback at all. Requesting ODM to reconsider the number of audit requests as they are becoming overwhelming and burdensome on organizations. |
Provider request to ODM |
| Closed Issues | ||
| Issue | Information | Status |
| Humana TOB rejections (added 1/31/24) |
A fix was implemented in mid-December 2023 to resolve a defect causing TOB rejections. Providers should resubmit impacted claims. | Resolved |
| Missing FFS 835s (added 1/17/24) |
Members are reporting missing FFS 835 files that started Jan. 2024. 1/18/24 update: These missing remits have been delivered. |
Resolved |
| Buckeye denying for missing/invalid POA indicator in error | Medicaid inpatient hospital claims submitted through the FI are denying for missing or invalid POA indicator (EXVV) in error. This issue is impacting behavioral health and medical Medicaid claims. EDI will need to remap how the POA indicators are sent from the fiscal intermediary. This issue is being reported as a CPSE issue, however, it won’t be available until the Mid-March 2023 CPSE submission. This is logged under CIA-5634. Ticket INC01182404 has been submitted for EDI to correct the issue. This issue is impacting the majority of all inpatient Medicaid claims submitted so the fix has been escalated. |
Resolved |
| CareSource duplicate denials | CareSource is returning EOBs with the old payer ID and claim type of 13 for processing. Members report getting rejections, duplicate billing denials, invalid claim type denials, and then eventually a payment all being created by CareSource from 1 claim submission. Example: 4 total EOBs generated from 1 claim submission – 3 denials with the 4th EOB finally paying. Another member reports CareSource is processing their claims multiple times resulting in duplicate denials. 3/21 update: CareSource states that it has been corrected in their system as of 3/10/23 and providers would not need to resubmit any claims with this denial (it appears that CareSource will reprocess impacted claims). 3/28 update: CareSource was advised that the issue at the FI that was causing the duplication was resolved on 3/13/23. However, providers are reporting that this issue has not been resolved. CareSource is investigating this issue. |
Resolved |
| Unlisted drug code J3490 (added 5/4) |
ODM shared: There was an open ticket for denials of J3490 on outpatient hospital claims. ‘Edit 162 – Contract Term Requires Documentation’ is posting in error. This issue was corrected on April 14, and there aren’t any claims to reprocess. | Resolved |
| Edit 205 posting incorrectly | ODM shared: There was an open ticket for edit 205 – Benefit Requires UM. This edit is posting on outpatient claims incorrectly. However, this issue was corrected on April 27, and claims are being reprocessed and should be completed by May 5. | Resolved |
| Inappropriate access for Non-Provider Enrollment agents | Non Provider Enrollment agents (e.g. Auth agents, Claims agents, etc.)are able to see Ownership Information (Board info- Sensitive information) 3/27 update: See ODM update. "In an effort to enhance security features and align agent roles closer to the needs of users, a Provider Network Management (PNM) module release is scheduled for March 28, 2023. This update will only allow users with the Enrollment Agent role to see “View Provider File.” If the agent does not have this role, they will no longer be able to view any of the provider data." |
Resolved |
| Combined FFS remits | ODM combined 2 weeks worth of payments onto one remittance. | Resolved |
| Missing FFS ERAs | ODM implemented a systems fix to address their missing FFS remittance advices. FFS remittance advices should be available in the PNM by Feb. 21. Note: All payers' .pdf remittance advices are available to providers on the PNM portal. This includes MITS, FI, and MCO RAs. If a provider is enrolled with ODM to receive an 835, that enrollment applies to both FFS and MCO activity. 835s from all payers are delivered by the trading partner. 3/9 update: Members are reporting varying experiences with this issue. Some are receiving 835 Medicaid remittance advice files for FFS Medicaid while others report not receiving these files from the trading partner. 3/16 update from member: "Our Posting Manager states: Contact information listed on Gainwell/Medicaid remits is either incorrect, or staff operating call lines do not know what they are doing. We have routed question to two different email addresses and been given phone numbers to random, unaffiliated companies (e.g. train station)." 3/20 update from members: "We are receiving EFTs but our ERAs are not coming through. This is FFS and managed care plans." "Not receiving 835s from Traditional Medicaid since 2/1/23." 3/20 note: Based on varying experiences reported by members, this issue may be trading partner-dependent. 3/27 update: Several organizations still report not receiving 835s. The issue appears to lie in the ODM platform and their ability to create the 835 and place it into the folder for trading partners to retrieve. ODM appears to be having issues with their 835 process, which is why they are directing providers to access the PNM provider portal. 5/10 update: ODM has acknowledged that there is an issue with the generation and distribution of 835s. Their system vendors are actively working on resolution, and as 835s are generated, they will be distributed. If your organization would like to see if any 835s have been generation for your organization, please send an email with impacted NPIs to Quyen Weaver. Your impacted NPIs will be provided to ODM for a status update. 6/2 update: More 835s have been generated for some organizations, however, the majority of the 835s are for professional claims. Some organizations still report not receiving any 835s. As a workaround, some organizations have opted to pay for a service that converts PDF RAs to 835s. 6/12 note from member: "We have recently received several 835 remits where a transaction is being posted to claims that have previously been processed. The batch remit is rejecting due to invalid information in the CLP segment which should be the claim number. We have had to look at the file to get the patients name and date of service to match up the transactions. For all that I have received so far from our posters these have been claims reprocessed for 2022 dates of service. We took no action to cause these claims to be reprocessed so we are reviewing further to see that might have triggered Medicaid to reprocess." 6/14: Members have reported missing PDF RAs from the PNM portal. ODM indicates that overall, PDF RAs are being posted to the PNM portal. ODM shared this quick reference guide in case it is helpful. ODM asks providers with missing PDF RAs to contact the IHD at 1-800-686-1516. 6/28: ODM has identified the issue causing 835s to not generate. A fix is being tested. See here for more information. 7/3 ODM email to trading partners: "ODM is aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch on February 1. ODM understands the importance of timely and accurate data exchange and is committed to ensuring a smooth and reliable user experience. Over the last few months, ODM and its vendors have been identifying and correcting 835-related errors. As a result of the fixes, the majority of missing 835 details have been generated. A large batch was released on May 24, followed by a second batch released on June 26, and we expect another batch to be released by July 7. There is one remaining known issue that is currently being addressed. ODM has identified that this issue is primarily affecting hospitals claims. These files cannot be delivered since they failed SNIP edits at the Electronic Data Interchange (EDI). ODM vendors are working on implementing a fix in the coming 2-3 weeks." 7/6: According to ODM, the issue of 835s not being created due to the previously reported DRG issue is not related to inbound claims. Additionally, ODM has stated that providers do not need to send DRG information. The missing 835s are a result of the adjudication and financial system not reporting the DRG information regarding how the claim was adjudicated. ODM has confirmed that this is an internal issue that it is actively working to resolve and all missing 835s will be delivered as soon as possible. 8/8 update: This issue has been resolved. See here (8/8 update) for more information. 8/15 update: Members report some 835 files are still missing. See here (8/14 update) for more information. Members have also reported duplicate payments that were paid on two different remits. |
Resolved |
| Taxonomy rejection | Rejections for taxonomy on both our hospital and professional claims: 8 SEGMENT HAS DATA ELEMENT ERRORS SEG TYPE: PRV POSITION: 33 LOOP: 2310 I6 CODE VALUE NOT USED IN IMPLEMENTATION ELEMENT POSITION: 3 DATA ELEMENT REFERENCE NUMBER: 127 COPY OF BAD DATA: 2080P0006X 6/2: Member hospital reports not receiving this rejection anymore. Nothing was changed in how the claims were submitted. |
Resolved |
10/23/23 Update – Ensure provider info in PNM is accurate by TBD Oct. 20
Starting Oct. 20th, MCEs will point to PNM as source of truth for provider information. Ensure all fields in PNM are accurate (e.g., physician affiliation to groups, specialties, service locations, etc.)
9/25/23 update: Click here for more information and recommendations.
10/10/23 update: Click here to view ODM's Oct. 5 training slide deck.
10/23/23 update: ODM delays claim denials for MCEs using PNM as official system of record for claims adjudication. Click here for more info.
10/23 Update – Fee-for-service claims reprocessing
Ohio Department of Medicaid (ODM) and its Ohio Medicaid Enterprise System (OMES) vendors are diligently focused on researching and resolving issues to improve the performance of the OMES system. As a result of these continued efforts, our claims processing vendor Gainwell Technologies is processing mass adjustments on fee-for-service (FFS) claims that ODM already adjudicated. Reprocessed claims have a modified Internal Control Number (ICN) for providers to reference if they need to submit future claim reversals or adjustments.
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Where can providers find the Internal Control Number? After reprocessing the claim, the ICN is visible on the .pdf remittance advice within the PNM module and on the 835 file sent from the Electronic Data Interchange (EDI), if you signed up to receive the 835 from ODM.
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What action do providers need to take? No action is needed by providers at this time. ODM will contact providers separately by email if action is required.
7/3 Update – Important notice regarding duplicate payments
Ohio Department of Medicaid (ODM) has identified an issue where some providers are receiving duplicate payments for fee-for-service (FFS) claims. This occurs when a provider submits FFS claims through both the Provider Network Management (PNM) module, which redirects to the Medicaid Information Technology System (MITS), and through a trading partner via the Electronic Data Interchange (EDI). Currently, these claims are processed independently from one another, resulting in two payments for the same service. One of these two payments is considered an overpayment.
What action do providers need to take?
Providers should return the overpayment by submitting a VOID for one of the duplicate claims. Providers can submit a VOID for one of the duplicate claims by using the same method as the original claim submission. Providers who do not void the overpayment will have future claims payment offset through an accounts receivable. Any amount not collected may be subject to interest and may be certified to the Ohio Attorney General’s Office for collection.
5/26 Update
See this document for more information on how to attach claims within the new PNM.
4/25 Update (from ODM email to trading partners)
ODM has identified 73 837 files submitted between Feb. 1 and March 15 which experienced a processing issue within the FI module. This issue resulted in some claims not being loaded for processing and adjudication.
ODM will be re-submitting these files internally to FI system by April 21 for processing and adjudication. Previously loaded and processed claims will be denied as duplicates in the 835 and remittance advice. Trading partners will receive a new 277CA for claims not previously loaded.
4/4 Update (from ODM email to trading partners)
On Monday, March 27, the Ohio Medicaid Enterprise System (OMES) relaxed four Strategic National Implementation Process (SNIP) edits for the processing of 837s. Trading partners will now be able to reprocess these claims without experiencing rejections due to the following SNIP edits:
Edit 1) Loop 2310B operating physician is missing.
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This relaxed edit rejected claims whenever the claim contained at least one service line with a procedure code within the range of 10000-69990.
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Per the 837 TR3 guide, the operating physician name is required whenever a surgical procedure code is submitted on the claim.
Edit 2) Billing provider specialty information is sent.
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This relaxed edit rejected claims whenever the provider specialty (taxonomy code) is sent for the billing provider level and the rendering provider or assistant surgeon.
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Per the 837 TR3 guide, the provider specialty (taxonomy code) should be sent at the billing provider level only in cases where that provider is also the rendering provider.
Edit 3) Ordering provider name or rendering provider name is sent.
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This relaxed edit rejected claims whenever the same provider information was sent at both the billing and ordering provider levels.
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Per the 837 TR3 guide, ordering provider information should be sent at the service line level only when it differs from what is sent at the billing provider level.
Edit 4) Rendering provider name or rendering provider name is sent.
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This relaxed edit rejected claims whenever the same provider information was sent in both the claim level rendering provider segment and the service line level rendering provider segment.
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Per the 837 TR3 guide, rendering provider information should be sent at the service line level only in cases that differ from what is sent at the claim level
3/2: ODM reprocessing FFS claims
Some FFS claims that were submitted by providers via a trading partner had been rejected on the 277CA due to the edits listed below. To fix this issue, these edits have been relaxed in FI and the impacted claims are being reprocessed. Providers do not need to resubmit the impacted claims. The reprocessing of these FFS claims will be completed by March 3 and trading partners will receive an updated 277CA by March 6.
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SNIP 4 edit: Value of element DTP02 is incorrect. Value 'DT' cannot be used when CLM05-01 is '21'.
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SNIP 2 edit: Value of element N403 is incorrect. Expected value for ZIP code is 9 digits.
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SNIP 5 edit: Value of element N403 is incorrect. Expected value is from external code list – ZIP Code (51) when country is US.
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SNIP 7 edit: The Release Information Code must have a value of Y.
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SNIP 4 edit: Admitting Diagnosis may be used only when claim involves inpatient admission.
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SNIP 4 edit: 2310C N3/N4 must be different from 2010AA N3/N4 (837D).
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SNIP 4 edit: 2310E N3/N4 must be different from 2010AA N3/N4 (837I).
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SNIP 4 edit: 2310E NM1 must be different from 2010AA NM1 (837I).
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SNIP 4 edit: 2310C N3/N4 must be different from 2010AA N3/N4.
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SNIP 4 edit: 2310C NM1 must be different from 2010AA NM1.
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SNIP 4 edit: Loop 2310E (Service Facility Location Name) is used. It should not be used when loop 2010AA is used with the same information.
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SNIP 2 edit: Validate ZIP code is 9 digits.
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SNIP 2 edit: Validate ZIP code length is always 5 or 9 digits.
3/2: 277CAs for AmeriHealth
For awareness, an issue that resulted in some trading partners not receiving 277CAs from AmeriHealth, which provides a claim acknowledgment when the FI receives the claim, has been resolved. This issue could have resulted in missing claims as trading partners have not received updates about claims. The 277CAs due to trading partners will be sent by March 5.
2/23: Updated guidance for EDI claims
CareSource originally shared guidance that they will accept electronic claims with dates of service pre- and post- 2/1/23 with their new Payer ID and MMIS. ODM has confirmed the billing scenario of using the new Payer IDs and MMIS regardless of date of service is accepted for all FFS and managed care claims submitted to ODM’s new EDI starting 2/1. The only exception to this scenario is Paramount claims because Paramount is not a continuing plan and ODM cannot accept their claims via the ODM EDI front door that have dates of service prior to 2/1.