ODM Updates Guidance on Who to Bill for Physical Health Services with OhioRISE 

Ohio Resilience through Integrated Systems and Excellence (OhioRISE) is an Ohio Medicaid managed care program offering specialized behavioral health services to children and youth with complex multisystem behavioral health needs. Since its July 2022 launch, nearly 20,000 children have been enrolled into OhioRISE behavioral health supports as well as Ohio Medicaid’s traditional physical health services. 

If you are a provider supporting OhioRISE enrollees, we want to ensure you know who to bill for the non-behavioral health services they receive. Invoicing for physical health services offered to OhioRISE enrollees is determined by which Medicaid health program they’re enrolled in: managed care or fee-for-service (FFS). 

First: Verify the enrollee’s main healthcare program.

You can check whether the child or youth you are serving is enrolled in Medicaid’s managed care or FFS program by taking any of the following three actions:

1. Log into MITS through the Provider Network Management (PNM) module and conduct a recipient search using the child or youth’s information. If you need help, check out the Accessing MITS Secure Portal from PNM Quick Reference Guide.
2. Call Ohio Medicaid’s 24/7 Integrated Helpdesk at 800-686-1516. Representatives are available 8 a.m.-4:30 p.m. Monday-Friday, ET.
3. Check the member’s Medicaid ID card and look for the OhioRISE logo. Be sure to check both the front and back of the card.

Second: Identify the appropriate billing entity.

Once you determine which Medicaid health program your OhioRISE client participates in, use the information below to identify the appropriate billing entity:

• If a youth or child is on Medicaid’s managed care program:
• Physical health services should be billed to their MCO (information in chart below).
• Pharmacy services should be billed to the Single Pharmacy Benefit Manager, Gainwell Technologies.
• If a youth or child is on Medicaid’s FFS program:
• Physical health services should be billed to Ohio Department of Medicaid.
• Pharmacy services should be billed to Change Healthcare.