Ohio medical billing and payer rules

Timely filing in Ohio

Ohio surprise billing vs the federal NSA

Fully insured plans regulated by Ohio follow Ohio's negotiation and arbitration process through the Department of Insurance. Self-funded employer plans follow the federal No Surprises Act and federal IDR. We confirm the plan type before filing either dispute.

Major payers

How does Ohio Medicaid billing work?

Ohio Medicaid is run by the Ohio Department of Medicaid (ODM), and a claim goes one of two ways: fee-for-service, which is processed by ODM's fiscal intermediary, or managed care, which is billed to the health plan the patient is enrolled in. Timely filing for claims sent to ODM is set by Ohio Administrative Code 5160-1-19, and that clock is the first thing a billing office should check on any aged Medicaid account.

On February 1, 2023, ODM implemented the Next Generation managed care plans, a new Electronic Data Interchange (EDI) and the Fiscal Intermediary (FI). Fee-for-service claims sent through the EDI are processed and paid by the FI. Managed care claims sent through the EDI are routed to the managed care organizations (MCOs) for processing and payment. Since June 30, 2024 the FI also processes fee-for-service claims and prior authorizations entered in the Provider Network Management module.

ODM's procurement page lists seven MCOs selected for the Next Generation program: AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Community Health Plan, CareSource Ohio, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio and UnitedHealthcare Community Plan of Ohio. That list dates from ODM's August 2022 update, so confirm current participation before you bill. OhioRISE, the program for children with behavioral health needs, gets behavioral health benefits through Aetna Better Health of Ohio, and physical health services through an MCO or fee-for-service.

A patient can switch between fee-for-service and a plan, or between plans, so one admission can touch two payers. Confirm which payer was responsible on the date of service, then bill on the right form: the UB-04 for facility claims and the CMS-1500 for professional claims.

Our Medicaid payer guide covers the national picture, and the managed care plans most Ohio hospitals see are on our CareSource and Molina Healthcare pages.

What is the Ohio Medicaid timely filing limit?

The Ohio Medicaid timely filing limit is 365 days from the date of service, or 365 days from the discharge date for inpatient hospital claims. Rule 5160-1-19(D), effective February 1, 2023, says a claim is timely if ODM receives it within that time. A denied claim that is resubmitted gets the same 365 days, measured from the date of service or discharge, and a provider-reported underpayment should be adjusted within 365 days as well.

Paragraph (E) lists exceptions. Claims that arrive through the automatic Medicare crossover process are not subject to timely filing. FQHC and RHC wraparound claims are timely within 180 days of the date the claim was paid. A claim delayed by an eligibility determination or state hearing decision is timely within 180 days of the notice, and one delayed by a third party payer's reversal of payment within 180 days of the recovery of funds.

Who is the Medicare MAC for Ohio?

The Medicare Administrative Contractor (MAC) for Ohio Part A and Part B claims is CGS Administrators, LLC, which holds Jurisdiction 15 (J15). CMS's list of MACs by state shows Jurisdiction 15 as Kentucky and Ohio, so a hospital in Cincinnati and one in Louisville bill the same contractor.

A MAC processes Medicare fee-for-service claims, handles enrollment, and runs the first level of appeal. Medicare's own filing limit is 12 months from the date of service under 42 CFR 424.44. Ohio providers who bill both Medicare and Medicaid for the same patient file Medicare first and track the crossover to Medicaid separately. CGS lists a myCGS web portal for Jurisdiction 15 on its home page.

Note that CMS's table also assigns home health and hospice (HH+H) claims to a different set of MAC jurisdictions, so a home health agency in Ohio should confirm its own contractor on the CMS page rather than assuming J15. Our Medicare guide explains the claim, appeal and enrollment steps.

What is Ohio's prompt pay law for insurers?

Ohio health insurers must pay or deny a claim within 30 days of receiving it when it is on the standard claim form. That rule is in Ohio Revised Code section 3901.381, and it applies to third-party payers such as insurers, health insuring corporations and administrators. A denial must be sent to the provider and the patient and must say with specificity why the claim was denied.

The deadline becomes 45 days when the payer needs supporting documentation to establish its responsibility to pay. The payer must say within 30 days what it needs, and the days between its last request and receipt of everything requested do not count. If a claim is materially deficient, the payer must say within 15 days what to correct. A mailed claim is presumed received on the fifth business day after mailing, and an electronic claim 24 hours after submission.

A payer that misses the deadline owes 18 percent annual interest from the day payment was due, paid directly to the provider (section 3901.389). For a consistent pattern of violations, the Superintendent of Insurance can order interest, issue a cease and desist order or fine the payer up to $100,000, then $150,000, then $300,000 for later offenses (section 3901.3812).

The law does not reach every plan. Section 3901.3814 excludes Medicare Advantage, Medicaid and TRICARE payers, and self-insured employer plans to the extent federal law preempts it. Those late claims run through the plan contract and federal ERISA claims rules. The clock also pauses during out-of-network negotiation or arbitration under sections 3902.51 and 3902.52, and restarts when a negotiation succeeds or an arbitration decision issues (section 3902.53).

What matters operationally is that the clock starts when the plan receives the claim, so proof of receipt is the evidence. We keep the clearinghouse acceptance report (the 277CA acknowledgment) for every claim, because a payer that says it never got the claim is answered with a dated payer-side acceptance, not a screenshot.

How does Ohio's surprise billing law work next to the federal No Surprises Act?

Ohio has its own surprise billing law for state-regulated health plans: House Bill 388 of the 133rd General Assembly, codified at Ohio Revised Code sections 3902.50 to 3902.54, with the Department of Insurance rule 3901-8-17, Reimbursement for unanticipated out-of-network care, written to carry it out. The federal No Surprises Act (NSA) still governs self-funded employer plans, where state insurance law does not reach.

CMS's letter to Ohio says Ohio has no All-Payer Model Agreement and that CMS understands ORC 3902.50 to 3902.54 are specified state laws for emergency services and for non-emergency services by nonparticipating providers at in-network facilities. Nonparticipating air ambulance providers go to federal IDR, and the Department of Insurance enforces the outcome. The state arbitration is run through the Department of Insurance, a different channel from the federal IDR portal.

The first question on every out-of-network emergency or facility claim is which plan type paid it. A fully insured plan regulated by Ohio goes down the state path. A self-funded plan goes to open negotiation and federal IDR. A plan we cannot classify gets an eligibility check before anyone files.

Here are the state rules as written in the statute and in rule 3901-8-17, effective January 1, 2022.

• Payment first. The plan sends its intended reimbursement, the greatest of the median in-network rate for the region, its usual out-of-network method, and the Medicare rate (section 3902.51(B)(1)). Cost sharing stays at the in-network level, and the provider cannot bill the patient the difference for covered unanticipated care (section 3902.51(C) and (D)).
• Negotiation. The provider must tell the plan within 30 business days of payment that it wants to negotiate. Silence counts as acceptance (rule 3901-8-17(I)).
• Arbitration eligibility. If negotiation has not concluded in 30 business days, or both sides agree they are at an impasse, the provider may request arbitration when the service was within one year and the billed amount is over $750. Up to 15 similar claims for the same plan may be bundled (section 3902.52(A)).
• Arbitration timeline. The Superintendent notifies the arbitration entity within 4 business days, an arbitrator is assigned within 10, each side files a final offer within 10 more, and the decision comes within 30 business days (rule 3901-8-17(J)).
• Decision and fees. The arbitrator picks one final offer and the decision is binding. The losing side pays 70 percent of the flat fee and the winner 30 percent. Billed charges and Medicare or Medicaid rates cannot be submitted as evidence (section 3902.52; rule 3901-8-17(J)).

The statute says the Superintendent contracts with a single arbitration entity that uses a secure electronic portal. We read these provisions from archived copies of the Ohio Laws site, so check the current rule text before each filing.

For how the federal process runs from open negotiation to a final decision, see out-of-network billing and IDR. For the full list of states and which ones have their own laws, see the state surprise billing law page.

Which payers matter most for Ohio hospitals?

The payer mix that decides cash flow for an Ohio hospital or emergency department is Medicare under CGS, Ohio Medicaid fee-for-service and the Medicaid managed care plans, and the commercial plans that sell fully insured and self-funded products in the state. We list on this page only the plans we have specific guides for, not market share.

Our payer guides cover Anthem, CareSource and Molina Healthcare, each of which is on ODM's list of Next Generation managed care plans. The same list names AmeriHealth Caritas Ohio, Buckeye Community Health Plan, Humana Healthy Horizons in Ohio and UnitedHealthcare Community Plan of Ohio. Plan participation changes at procurement, so check ODM's current list before you rely on a name.

Patients cross borders, so a hospital near the state line sees residents of Pennsylvania, Michigan and Kentucky, where the Medicaid rules, prompt pay law and surprise billing process differ.

What changes for Ohio emergency departments?

Emergency departments feel both laws first, because emergency care is where unanticipated out-of-network bills start. An out-of-network emergency physician group or facility in Ohio has to sort every underpaid claim into the state or federal track by plan type and then work it before the deadlines on that track expire.

Our emergency medicine billing page covers the codes and documentation for the professional side. Our hospital and facility billing service covers the UB-04 claim, with bill type, revenue codes and patient status checked before submission. Ohio's Medicaid rule that inpatient timely filing runs from discharge also matters for ED visits that turn into admissions: the admission claim and the ED claim are tracked on their own dates.

What should an Ohio billing office check before a claim goes out?

Check five things before any Ohio claim leaves the building: the payer on the date of service, the filing clock for that payer, the plan type if the claim may become a dispute, the form, and the proof of delivery. Most Ohio write-offs we see in aged accounts trace back to one of these five, not to a coding error.

1. Confirm eligibility on the date of service, and for Medicaid patients confirm whether fee-for-service or a managed care plan was responsible that day.
2. Write the filing deadline on the account at registration: 365 days for Ohio Medicaid, 12 months for Medicare, the contract number for commercial plans.
3. For out-of-network emergency or facility care, record whether the plan is fully insured or self-funded, because that sets the dispute track.
4. Match the form to the claim: UB-04 for the facility, CMS-1500 for the professional service, with bill type, revenue codes and patient status checked on the UB-04.
5. Keep the clearinghouse acceptance report and the payer response for every claim, so a late payment complaint or a timely filing appeal has dated proof.

How we handle billing in Ohio

For Ohio clients we sort every claim by payer type on day one: Medicare under CGS J15, Ohio Medicaid fee-for-service or a managed care plan, fully insured commercial, or self-funded. That sort decides the filing clock and, for out-of-network claims, whether the dispute goes to Ohio's Department of Insurance process or to federal IDR.

Claims go out within 24 hours of charge entry and denials are worked within 48 hours. We track the Medicaid 365-day and 180-day dates on the account, not in a spreadsheet someone has to remember. If you want to talk through your Ohio payer mix, book a call.