Pharmacy claims are processed by ODM’s contracted pharmacy benefits manager (PBM) in an online, real-time environment which allows the dispensing pharmacist access to the terms of coverage. The capabilities of the system include response messaging which may help in claims processing. Both the pharmacy and prescriber National Provider Identifier (NPI) are required on all POS and paper claims submissions. Claims submitted with a service provider ID other than NPI will be rejected. Please note:
- The pharmacy's NPI should be submitted in NCPDP version 5.1 field #201-B1 (service provider ID), with field #202-B2 (service provider ID qualifier) submitted as 01 (NPI).
- The prescriber ID in fields #411-DB (prescriber ID) and #466-EZ (prescriber ID qualifier) must be submitted as NPI (qualifier 01).
Disclaimer: Effective April 1, 2015, prescriptions will not be covered unless the prescriber is enrolled with Medicaid as an active provider. Prescribers may enroll as either an “ordering/referring/prescribing (ORP)” provider or as a billing provider. For additional information please refer to Provider Enrollment.
For additional information on claims processing please review the Ohio Medicaid Provider Manual and the Ohio Medicaid payer sheets:
- Provider Manual (DOWNLOAD)
- Payer Sheets-Effective 6/12/2016 (Eligibility E1)
- ODM Pharmacy Claims Review Provider Manual July 2018
- Claims Payer Sheet Effective 4/1/2017 (DOWNLOAD)
Summary of April 1st, 2017 Program Changes: On April 1st, 2017, the Fee-for-Service program for Ohio Medicaid will be making several program changes related to provider reimbursement. These changes impact reimbursement for the ingredient cost portion of a product as well as provider dispensing fees. Ingredient cost reimbursement will change from an estimate of acquisition cost to reimbursement based around actual acquisition cost. Dispensing fees will move from a flat rate to a tiered rate based upon pharmacy claim volume. Additional information regarding these changes can be found in the FAQ below.