Providers should contact the associated managed care organization (MCO) for assistance before submitting a complaint (see hyperlink below) to the Ohio Department of Medicaid (ODM).
Providers should contact the MCO’s provider services line and or their regional provider relations representative. Providers are encouraged to utilize the appeals, grievance, or arbitration processes as outlined in their individual contract with that plan. If the plan or plan’s representative do not return a provider’s call within 5 business days, providers may complete the provider complaint form below.
All complaints submitted are immediately sent to the corresponding MCO for response. Please note the plans will have up to 15 business days to respond.
The provider complaint guidance document and complaint form are located HERE.
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Patients must be eligible for Medicaid and enrolled in a MCP for claims to potentially be covered by a MCP. Providers are responsible for confirming Medicaid eligibility and the MCP enrollment for their patients.
The ODM has two sources for eligibility and enrollment.
Information online through the Medicaid Information Technology System (MITS)
If a MCP portal is not showing member enrollment, but MITS information shows eligibility and enrollment with the MCP, please use the online provider complaint form and select 'eligibility issue' to report the issue, so that the MCP can correct their system.
Unlike the Medicaid Fee-For-Service (FFS) program, MCPs are permitted to selectively contract with providers. ODM closely monitors MCP provider panels to ensure member access to services.
In order to comply with federal rules (42 CFR 438.602), providers must apply to the ODM, in order to continue providing services through one of the MCPs.
The enrollment process is electronic, and completion takes only a few minutes. To begin, please follow the steps outlined below in "How to Submit a Provider Application."
Providers whose current number expired and did not obtain a new Medicaid ID, will not be able to be reimbursed for any services and will need to follow the steps below in "How to Submit a Provider Application," in order to be considered for reenrollment.
How to Submit a Provider Application
View the status of your application using your Application Tracking Number (ATN). If you need any assistance, please contact our Provider Enrollment Hotline at (800) 686-1516.
For information about contracting with our MCPs, please contact the plans directly. The MCP credentialing process must be completed no later than 90 days after the provider submits both the credentialing form and the provider's national provider identification number issued by the Centers for Medicare and Medicaid Services (CMS) to the MCP. The 90-day timeframe is inapplicable to providers that are hospitals, all providers not solicited to be credentialed, and any individual or entity not listed in the definition of 'provider' in Ohio Revised Code 3963.01 (P).
Additional information concerning the credentialing process, including a Credentialing and Contracting Provider Complaint Form and key definitions, is available from the Ohio Department of Insurance (ODI).
Visit MCP provider portals; peruse prior authorization policies, reimbursement policies, newsletters, and other materials.
MCPs are not required to reimburse providers who do not have a contract or a provider reimbursement agreement in place of a contract. Providers, who are not contracted with a MCP, but who are authorized under agreement with the MCP to provide service to its members, must ensure they have a written and mutually agreed compensation schedule prior to rendering service.
There are limited exceptions: MCPs must pay for medically-necessary services for newly enrolled members during their transition periods, but providers must verify with the MCP before rendering services.
MCPs may deny claims for coordination of benefits (primary insurance), because Medicaid, including Medicaid-contracting MCPs, is the payor of last resort. Exceptions include: services provided under Title V and similar programs outlined in OAC 5160-26-09.1 . MCPs must provide coordination of benefits as outlined in the rule. If the patient denies having primary insurance, please contact the MCP's customer service/regional provider relations representative to obtain further information regarding the primary payer.
It is up to the provider to establish a noncontracted reimbursement agreement (single case agreement) with the MCP in order to continue seeing an MCP's members, if a provider has not yet completed contracting and credentialing. If the MCP is not willing to establish an agreement with a provider, then members must seek services from a contracted provider. In most situations, providers are not allowed to directly bill the member, even if the MCP refuses to reimburse the provider, and the provider chooses to continue seeing the member.
Please verify Medicaid eligibility through the MITS provider portal. The provider portal contains information about: member eligibility spans, managed care enrollment, patient liability, and Restricted Medicaid Coverage Period (RMCP). Additional resources are available.
Members covered under MyCare Ohio or the Adult Extension eligibility categories may qualify for long term care (LTC) services in a nursing facility or through a home and community-based services (HCBS) waiver if:
Members of these groups will not be subject to disenrollment while receiving LTC services. Only MCPs can request patient disenrollment for non-Adult Extension members in nursing facilities for longer term stays.
Contact the MCP involved to report admission of a patient; to confirm the category of Ohio Medicaid provided; and to request authorization and payment for MyCare Ohio or Adult Extension Medicaid managed care members. MCPs can pay for short-term rehabilitative stays for members who are not part of the Adult Extension program.
Managed Care Plans (MCPs) have contractual requirements with ODM for prompt pay. MCPs must pay 90% of all submitted clean claims within 30 days of the date of receipt and 99% of such claims within 90 days of the date of receipt, unless the MCP and its contracted provider(s) have established an alternative payment schedule that is mutually agreed upon and described in their contract. For managed care plans, the following claim types will be separately measured against the 30 and 90 calendar day prompt pay standards:
For MyCare Ohio plans, the following claim types will be separately measured against the 30 and 90 calendar day prompt pay standards:
MCPs are not required to use the same coding systems as Medicaid Fee-For-Service (FFS), though all plans must HIPAA compliant coding and files. MCPs are also not required to reimburse services at the same payment rate as the Medicaid FFS program. Please refer to your organization's provider agreement, the MCPs' provider manuals, and the MCPs' provider portals for clinical coverage policies, reimbursement policies , and other tools. Those tools will assist you with resolution of issues regarding contracted fees, grievance and appeal procedures, and contractual disputes. All providers must follow the grievance and appeal procedures outlined in their contracts with the Medicaid Managed Care Plan (MCP) or MyCare Ohio Plans (MCOP).