[Ohio] August 2026 Provider Newsletter

REQUIREMENTS: This newsletter contains multiple policy updates with staggered effective dates requiring coordinated action: 1. By September 1, 2026: Billing team must review and implement changes to: - Telehealth claims ICD-10-CM Excludes1 editing (Medicare Advantage/Medicaid) - Observation service billing per CMS requirements (Medicare Advantage) - Verify all required NPI information in system to prevent utilization management notification delays (Medicaid/MyCare Ohio) 2. By September 14, 2026: Implement electronic remittance advice improvements in billing system (MyCare Ohio) 3. By October 1, 2026: CRITICAL - Transition all claims to no-cost electronic submission to avoid paper administrative fees (Commercial/Medicare Advantage). Update billing software and staff workflows accordingly. Failure to comply will result in administrative fee penalties. 4. By October 1, 2026: Implement behavioral health provider office hours authorization changes (Medicaid/MyCare Ohio) 5. By November 1, 2026: Implement ALL new reimbursement policies: - New policy for Modifiers 90, 91, 92 for laboratory services (Commercial) - New policy for Emergency Department E/M leveling (Medicaid) - Updated sleep studies and related bundled services policy (Commercial) - Precertification/prior authorization requirement changes (Medicare Advantage/MyCare Ohio/Medicaid) - Site of Care Program expansion for surgical procedures (Commercial) - Specialty Pharmacy precertification list expansion (Medicare Advantage) - Clinical criteria updates (Medicaid/MyCare Ohio) 6. By December 1, 2026: Update precertification/prior authorization list per change notifications (Commercial) 7. By January 1, 2027: Prepare for Medicaid 2027 work requirements implementation - educate providers on changes affecting care delivery ACTION OWNERS: Billing team must update software rules, encounter forms, and training materials. Providers must be notified of authorization requirement changes before effective dates. Front-desk staff should be trained on electronic claims requirements. CONSEQUENCES: Claims submitted on paper after October 1, 2026 will incur administrative fees. Non-compliance with updated prior authorization requirements will result in claim denials. Failure to implement required edits will cause claim processing delays.