Billing Guides. The following principles must be incorporated into the creation and use of the MCO's billing guides. The MCO must: Collaborate with ODM when developing billing guides to minimize the complexity of conducting business with the State Medicaid agency. Utilize the Provider Master File to adjudicate claims. The MCO must use this information to minimize the impact on provider billing requirements and reduce provider denials and resubmissions. Follow the X12/TR3 industry standard when implementing changes. Follow Council for Affordable Quality Healthcare, Inc. (CAQH) Committee on Operating Rules for Information Exchange (CORE) mandated timeframes with specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) on the 835 transaction of the outcome. The MCO must submit to ODM the same outcome reported to the providers. Participate in any meetings, workgroups, or other activities related to billing guides as directed by XXX. The MCO must notify ODM for review and approval prior to implementation of any changes to billing guide policies or procedures.
Billing Guides i. The following principles must be incorporated into the creation and use of the OhioRISE Plan’s billing guides. The OhioRISE Plan must:
1. Collaborate with ODM to minimize the complexity of conducting business with the State Medicaid agency.
2. Utilize the Provider Master File to adjudicate claims. The OhioRISE Plan must use this information to minimize the impact on provider billing requirements and reduce provider denials and resubmissions.
3. Follow the X12/TR3 industry standard when implementing changes.
4. Follow Council for Affordable Quality Healthcare, Inc. (CAQH) Committee on Operating Rules for Information Exchange (CORE) mandated timeframes with specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) on the 835 transaction of the outcome. The OhioRISE Plan must inform the providers of the outcome on the encounter submissions to ODM.
5. Participate in any meetings, workgroups, or other activities related to billing guides as directed by XXX. The OhioRISE Plan must notify ODM for review and approval prior to implementation of any changes to billing guide policies or procedures.
