The Ohio Department of Medicaid (ODM) recently confirmed that nursing facilities (NFs) may resubmit claims denied due to system edits that were implemented after the launch of OMES:FI. Following a claims review and conversations with OHCA, three billing errors were identified as the root cause of many recent denials:
These billing errors trigger edits designed to ensure proper processing and payment. For current claims still within the timely filing window, providers should make the necessary corrections and resubmit through the standard claims submission process.
However, ODM recognizes that some providers were unaware of these issues on older claims that have since been denied due to system-initiated adjustments. Because providers cannot retroactively edit claims once they are outside the timely filing window, ODM is allowing NFs to resubmit these older claims through the Medical Claim Review Request process using the ODM 6653 Form.
To support this effort, ODM has released step-by-step guidance for each of the three billing scenarios. Providers should carefully review and follow the relevant instructions to ensure successful claim resubmission:
ODM will also address these billing scenarios directly with affected providers through an upcoming overpayment and recoupment project. In the meantime, LeadingAge Ohio encourages members to begin reviewing their denied claims and resubmitting any eligible items using the process outlined above.