[Ohio] September 2026 Provider Newsletter

REQUIREMENTS: By December 1, 2026: Billing team must implement multiple changes: 1. For Medicaid plans: Update billing software to require modifier 25 when billing eligible E&M services with XXX procedures. Train providers and billing staff on new modifier usage. Update encounter forms and EMR templates to remind providers to append modifier 25. Claims without appropriate modifier 25 will be denied. 2. For Medicare Advantage and Medicaid: Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services. Update fee schedules and billing system validation rules. Educate lab staff on modifier 90/91 usage requirements. 3. For Commercial plans: Update facility guidelines for claims related to professional services. Review current facility billing practices and adjust claim submission accordingly. System updates required in billing software. By October 1, 2026: Billing team must review and implement prior authorization requirement changes for Medicaid pharmacy (prior authorization and step therapy updates for medications billed under medical benefit). Update PA submission processes and provider notifications. By January 1, 2027: Implement new ordering, rendering, and prescribing (ORP) provider requirements for Medicaid/MyCare Ohio. Update credentialing files and provider records. Notify affected providers of new requirements. Immediate: Access Ohio Medicaid prior authorization request forms (Substance Use Disorder form, home healthcare/waiver services/private duty nursing authorization, perinatal risk assessment) from provider portal. Review Excludes1 notes effective October 1, 2026 for Commercial claims to ensure accurate coding and reduce denials. Review ASC claims guidance for Medicaid/MyCare Ohio to ensure CMS-1500 and UB-04 forms are correctly formatted.