NextGen Updates

Exciting changes to Ohio’s Medicaid program effective February 1.

On February 1, 2023, Ohio Medicaid implemented exciting improvements for managed care members and providers.

What AmeriHealth Caritas Ohio Medicaid members need to know:

The Next Generation managed care plans will provide personalized benefits to members that best meet their individual healthcare needs. The Next Generation program is designed to address health inequities and disparities and achieve optimal outcomes for the holistic well-being of individuals receiving Medicaid.

The Next Generation managed care plan changes do not apply to the MyCare Ohio program, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.

Ohio Medicaid managed care members should have received a Next Generation Ohio Medicaid managed care member ID card prior to February 1, 2023, from AmeriHealth Caritas Ohio. On February 1, 2023, members should have begun using that card when going to the pharmacy or their physician.

Sample image of the new Next Generation Ohio Medicaid managed care member ID card

If a member hasn't received a new member ID card, they can still receive services and have prescriptions filled. Members should bring their old ID card with them to the provider or pharmacy and contact AmeriHealth Caritas Ohio at 1-833-764-7700 (TTY 1-833-889-6446) to learn more about how to print their new card or access an electronic version.

If a member needs to request a new member ID card, please contact AmeriHealth Caritas Ohio at 1-833-764-7700 (TTY 1-833-889-6446) to learn more about how to print their card or access an electronic version.

Ohio Medicaid managed care members are encouraged to visit the Ohio Medicaid Managed Care website for additional resources and information about the latest launch of Ohio Medicaid’s Next Generation program.

Help desks are available:

  • If a member has a question about Medicaid managed care eligibility, coverage, benefits, managed care plan selection, or something else, contact the Ohio Medicaid Consumer Hotline at 1-800-324-8680.
  • If a member has questions about their Next Generation managed care plan member ID card, contact Member Services at 1-833-764-7700 (TTY 1-833-889-6446).

What Ohio Medicaid providers need to know:

The Next Generation managed care plans, new Electronic Data Interchange (EDI) module, and Fiscal Intermediary (FI) have been implemented. With the launch of the new EDI and FI, there are some activities for providers that have stayed the same and some that have changed.

Claims and prior authorization (PA) submitted through a trading partner

What are the key changes on February 1?

  • ODM’s new EDI begins accepting trading partner fee‐for‐service (FFS) and managed care claims.
  • Provider claims submitted to trading partners must include the Medicaid member ID (MMIS).
    • Medicaid ID should be obtained with each encounter.
    • Member eligibility can be verified using the ID through the Provider Network Management (PNM) module, which redirects to MITS.
  • For professional claims, only one rendering provider is allowed per claim. Individual claims must be submitted for services rendered by different providers. (See exceptions for federally qualified health centers and rural health clinics in “Rendering Provider on Claims Submissions.”)

What is not changing February 1?

  • FFS claims and PAs will continue to be submitted through the PNM module link to MITS.
  • Managed care PAs will continue to be submitted to each plan using their existing processes.
  • The new EDI will not accept PAs of any kind.

Portal submitted claims and all prior authorizations

What are the key changes on February 1?

  • All Next Generation plans will have portals for direct data entry and providers should consult their provider handbook for instructions on how to bill using the portal.
  • MMIS ID will be the identifying number used for FFS claims processing.

What is not changing February 1?

  • Continue using managed care plan portals to direct data enter claims and PAs.
  • Plan eligibility will continue to be accessed through MCO portals.
  • Continue using the PNM module, which redirects to MITS, as you do today to submit, adjust, and search FFS claim and PA information. 

The Next Generation managed care changes do not apply to the MyCare Ohio program, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.

For additional information and resources about the February 1 launch, visit the provider resources webpage of the Next Generation website.

Help desks are available to assist providers:

  • If you have questions about streamlined claims, prior authorizations, administrative processes, the PNM module, OH|ID, or portal password support, contact the ODM Integrated Help Desk (IHD) at 1-800-868-1516 or IHD@medicaid.ohio.gov.

For billing and prior authorization guidance, contact Provider Services at 1-833-644-6001.

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