Provider Tools for Navigating Managed Care Coverage
Verify Coverage for All Patients
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)
- Information through Interactive Voice Response lines at (800) 686-1516.
- The first response states patient eligibility;
- The second prompt provides the patient's managed care plan enrollment, if any.
Contact the Managed Care Plans if you have questions or are experiencing challenges
Visit MCP provider portals; peruse prior authorization policies, reimbursement policies, newsletters, and other materials.
|MCP Name||Medicaid||MyCare Ohio|
Be familiar with your contract
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.
Long Term Care Disenrollment
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:
- they are Medicaid-eligible AND
- they meet the applicable level of care.
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.
Prompt Pay Standards
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:
- nursing facility
- behavioral health, and
- all other clean claim types.
For MyCare Ohio plans, the following claim types will be separately measured against the 30 and 90 calendar day prompt pay standards:
- nursing facility/hospice room and board
- behavioral health
- waiver services, and
- all other clean claims types.
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).