ODM Phase 3 Implementation

Starting December 1, 2022, Medicaid Managed Care (including OhioRISE) and Fee-for-Service claims and prior authorizations will be submitted through the Ohio Medicaid Enterprise System (OMES). As a reminder, MyCare Ohio claims and prior authorizations are not included in this transition and will continue to be sent to the MyCare Ohio managed care plan. Upon submission of claims and prior authorizations by providers and trading partners to the Provider Network Management (PNM) portal or Electronic Data Interchange (EDI), the Fiscal intermediary (FI) will facilitate processing for these transactions. In coordination with EDI, FI will assist in transitioning claims and authorizations to Ohio Medicaid’s managed care entities as well as receive updates back from those organizations so providers can receive appropriate updates, making the process more transparent and efficient. The Fiscal Intermediary will also provide ODM with greater insight into claims and prior authorizations requests, allowing ODM to more effectively identify and address trends.

Deloitte is the new EDI vendor for ODM. EDI transactions for dates of service on or after 12/1/22 must go through the EDI module. Only authorized trading partners will be able to exchange EDI transactions. If providers submit EDI transactions and do not use a clearinghouse, it is recommended to contact Deloitte. EDI claims transactions must only contain claims destined for the same payer (ODM/FFS or the MCE). Each payer has specific identifiers that must be included in the file so that EDI will know where to direct the claims for adjudication. Those identifiers are available in the EDI companion guides (Future OMES Encounters). The Ohio Council recommends members using a clearinghouse for claims submission contact their vendor to ask about preparations for working with ODM through these transitions.