IMPORTANT guidance on claims and payments for PNM module and MITS

Hello,

The Provider Network Management (PNM) module is currently experiencing intermittent connectivity interruptions with the Medicaid Information Technology System (MITS). We appreciate your patience as we are working with our vendors, Maximus and Gainwell, to resolve the issue as quickly as possible and to improve help desk wait times.

In light of this issue and to ensure providers receive payment in alignment with Ohio Medicaid’s normal adjudication cycle, the Ohio Department of Medicaid (ODM) will process an advance estimated Medicaid claims payment to all providers who may have experienced issues submitting claims between October 1 and October 7, 2022, at 5 p.m. ET.

This process applies to any providers that billed through the portal using direct data entry such as independent providers, private ICFIIDs, and any other group practitioners or providers that bill using direct data entry. This does not apply to claims submitted via trading partners to EDI, which continues to operate and adjudicate claims as normal.

The Advance Estimated Medicaid Claims Payment will be determined as follows:

• Assess average weekly payment amount.
• ODM will analyze claims submitted to MITS for the three (3) months preceding October 1 to determine the provider’s weekly average payment.
• ODM will take the weekly average payment and multiply that amount by two (2).
• Calculate advance payment amount.
• ODM will then determine if the provider successfully submitted claims in MITS from October 1 to October 7 at 5 p.m. ET. If so, ODM will subtract the total amount successfully billed from the estimated advance payment.
• The resulting amount will be the advance payment amount the provider receives.
• Issue payment.
• Providers receiving advance payments will only receive one payment containing both the submitted claims and the advance payment amount. Remittance advices will properly notate the advance payment compared to the claims payment.
• Regarding timing for payment: in alignment with the normal payment schedule, on Friday, October 14, 2022 (due to Monday, October 10, 2022, being a State holiday), providers will receive the estimated payment and, if applicable, their normal payment for claims.
• Payments will be made to providers via EFTs or paper checks will be mailed; the method of payment will be consistent with the provider’s normal payment method.

Example: Advance Estimated Medicaid Claims Payment

To calculate an advance payment for Provider A, ODM will do the following:

• Assess average weekly payment amount.
• During the three (3) months preceding October 1, Provider A’s average weekly portal average claims payment was $100.
• Calculate advance payment amount.
• Provider A’s average three (3) month payment multiplied by two is $200.
• Provider A successfully submitted claims from October 1 – October 7, 2022, in MITS that total $25.
• The advance payment ODM will issue is $200 minus $25, which equals $175.
• Issue payment.
• Provider A receives Medicaid payments by EFT.
• On October 14, 2022, Provider A will receive one EFT payment for $200. This reflects:
• $175 advance payment.
• $25 normal payment for successfully submitted claims.

We appreciate your patience during this time as we work to resolve PNM’s intermittent connectivity interruptions with MITS. If you have additional questions, please contact Medicaid@medicaid.ohio.gov.