Medical Billing Services in Ohio
Ohio practices send Medicare claims to CGS Administrators, fee-for-service Medicaid claims to the Ohio Department of Medicaid (ODM), and the rest of their Medicaid volume to one of seven managed care plans. We handle the billing work for Ohio practices remotely across 15+ specialties.
Who Pays Medical Claims in Ohio
Who gets the claim in Ohio, and through which door.
Jurisdiction 15
Ohio Part A and Part B claims go to CGS Administrators, A/B MAC Jurisdiction 15, which also covers Kentucky. Home health and hospice claims are processed by Palmetto GBA (Jurisdiction M). DME claims go to DME MAC Jurisdiction B, which is also CGS.
Ohio Medicaid (ODM)
Run by the Ohio Department of Medicaid. Fee-for-service claims go to ODM electronically through EDI or by direct entry in the Provider Network Management (PNM) module, and ODM does not accept paper claims unless it says otherwise. Gainwell Technologies pays fee-for-service claims as ODM's fiscal intermediary.
Seven plans, plus MyCare
The seven managed care plans are AmeriHealth Caritas Ohio, Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, Humana Healthy Horizons in Ohio, Molina Healthcare of Ohio and UnitedHealthcare Community Plan. Adults with both Medicare and Medicaid can be in Next Generation MyCare, offered statewide by Anthem, CareSource and Molina. Buckeye is closed to new MyCare members in 2026.
Ohio's plan programs and rollout dates have shifted in recent years, so we confirm each patient's plan at eligibility. Commercial and Medicare Advantage plans are billed under their own contracts.
Ohio Medicaid Billing Rules to Know
From Ohio Administrative Code and ODM provider guidance. Rules get amended, so confirm before relying on a date.
365 days from the date of service
ODM must receive a claim within 365 days of the date of service, or of discharge for inpatient hospital claims. Resubmitted denied claims and adjustments to underpaid claims count against the same 365 days.
Exceptions to the 365 days
A claim delayed by an eligibility decision or state hearing is timely if ODM receives it within 180 days of the notice or decision. If a third party reversed a payment, the adjusted claim is timely within 180 days of the recovery of funds. Medicare crossovers that come through the automatic crossover process are not subject to the limit, and FQHC and RHC wraparound claims have 180 days from the date the claim was paid.
Provider data on the claim
A claim that needs a rendering, supervising, ordering, referring or certifying provider must carry that provider's NPI and legal name, and the provider needs an active Medicaid provider agreement. Since February 1, 2023, professional claims sent through EDI also carry one rendering provider per claim at the header level.
Sources: Ohio Administrative Code Rule 5160-1-19; ODM Managed Care guidance on submitting claims and on the Next Generation program; Ohio Medicaid Consumer Hotline plan lists; CMS Who Are the MACs.
What Makes Ohio Medical Billing Different
What we keep an eye on for Ohio accounts.
Why Ohio claims take a detour
Since February 1, 2023, managed care claims sent through a clearinghouse go to ODM's central EDI first and are then routed to the member's plan. Fee-for-service claims use the same front door. Plans still run their own portals, prior authorization and attachments, while provider credentialing is centralized in the PNM module. On top of that, Next Generation MyCare rolled out across Ohio between January and August 2026, so a dual-eligible patient may now have a different plan for the Medicaid side of the claim. We tie prior authorization and plan checks together so a claim does not go to a payer that is no longer the right one.
What We Handle for Ohio Practices
The same work whether the claim goes to ODM, a managed care plan or Medicare.
Eligibility checks that confirm the plan and program, including MyCare
Prior authorization requests and tracking with each plan
Medical coding and charge review
Claim submission to CGS, ODM, the managed care plans and commercial payers
Denial management, appeals and A/R follow-up
Payment posting, patient statements and monthly reporting
Specialties We Support in Ohio
15+ specialties served. Pick yours to see how we bill it.
Ohio Medical Billing Questions
A few things Ohio practices ask us.
Who processes Medicare claims in Ohio?
CGS Administrators handles Part A and Part B as the A/B MAC for Jurisdiction 15, which covers Ohio and Kentucky. Home health and hospice claims go to Palmetto GBA (Jurisdiction M). DME claims go to the DME MAC for Jurisdiction B, also run by CGS.
How long do I have to file an Ohio Medicaid claim?
Under OAC 5160-1-19, ODM must receive the claim within 365 days of the date of service, or discharge for inpatient hospital claims, with limited exceptions for eligibility delays, third-party reversals and similar cases.
Do managed care claims go to ODM?
Claims for members in a plan are paid by the plan. Through a clearinghouse they travel via ODM's EDI and are routed to the plan. If you key claims yourself, you use the plan's own portal. Hand-keyed fee-for-service claims go in the PNM module.
Which specialties do you support for Ohio practices?
We support 15+ specialties for Ohio practices, from behavioral health and laboratory to home health, hospice, infusion, sleep medicine, DME, dental, vision and ENT.
Can Salyx RCM bill for my Ohio practice remotely?
Yes. Our team works remotely, logging into your practice management or billing software with secure access.
See What Is Holding Up Your Ohio Claims
Start with a free billing audit: a review of your recent claims, denials and A/R, with a summary of what we found.