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Effective January 1, 2026, MyCare Ohio transitioned to its Next Generation program, moving dual-eligible members onto a coordinated Medicare-Medicaid plan model. The Ohio Department of Medicaid awarded the contracts to four managed care organizations: Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina HealthCare of Ohio. A billing workflow built around the prior MyCare structure needs to account for this transition directly rather than assuming the old plan roster still applies.
OhioRISE is a specialized program for children and young adults with complex behavioral health and multisystem needs. Enrollees receive behavioral health benefits through Aetna, the single statewide OhioRISE plan, while their medical, dental, and vision benefits continue through whichever of the seven other managed care programs, or fee-for-service Medicaid, they're otherwise enrolled in. A practice treating this population needs a workflow that recognizes when a claim belongs to OhioRISE rather than the member's general medical plan.
Ohio's surprise-billing law took effect January 12, 2022, and prohibits balance billing for emergency and certain out-of-network services at in-network facilities. HB 388 extends further than the federal No Surprises Act in one respect, covering ground ambulance billing, and narrower in another, applying only to fully-insured health plans while self-funded employer plans stay under the federal process. A dispute that isn't resolved directly goes to baseball-style arbitration, where each side submits a final offer and a neutral arbiter picks one. Tracking which of the two frameworks actually governs a claim, and which arbitration path follows from that, is a distinct compliance step a generic out-of-network workflow skips.
Ohio and Kentucky fall under Medicare Administrative Contractor Jurisdiction 15, administered by CGS Administrators, which was re-awarded the contract through December 2030. This is a different MAC than the jurisdictions covering most of the Northeast and Mid-Atlantic, with its own claim-submission portal, EDI enrollment process, and local coverage determinations.
Claims submission built around Ohio's current MyCare and OhioRISE structures, not an outdated plan roster.
Learn MoreFull-cycle RCM that tracks HB 388's arbitration eligibility and CGS Jurisdiction 15 requirements as distinct, trackable processes.
Learn MoreProvider enrollment across Anthem, Medical Mutual, CareSource, and the regional hospital networks your referrals come from.
Learn MoreA free audit that checks specifically for missed OhioRISE routing and HB 388 arbitration eligibility.
Learn MoreFront-desk and administrative support that scales with a growing Ohio practice without new office overhead.
Learn MoreBenchmarks your claims data against current Ohio payer-specific denial patterns, including the Next Generation MyCare transition.
Learn MoreLocal visibility support built for a market split between major metro referral networks and regional systems.
Learn More| Ohio Regulation | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| Next Gen MyCare | Routing dual-eligible claims through legacy, uncoordinated billing tracks instead of the coordinated MCO models active since Jan 2026. | We configure claim submitter profiles for Anthem, Buckeye, CareSource, and Molina's coordinated plans. |
| OhioRISE Carve-Out | Submitting pediatric complex behavioral health claims to a patient's primary medical MCO, leading to immediate eligibility denials. | We identify eligible patients pre-visit, routing all complex behavioral health claims directly to Aetna OhioRISE. |
| House Bill 388 (HB 388) | Applying federal No Surprises Act rules to fully-insured commercial claims that fall under Ohio's state-specific baseball-style arbitration. | We audit plan funding types (fully-insured vs self-funded) and file disputes within statutory negotiation timelines. |
| CGS Jurisdiction 15 | Failing to align institutional and professional clearinghouse submitter IDs with CGS Administrators' specific MAC guidelines. | We verify clearinghouse and EDI enrollment parameters, adhering to local coverage determinations for Jurisdiction 15. |
We check your last 90 days of claims for missed OhioRISE behavioral health routing and coordinated Next Gen MyCare billing errors.
A written plan targeting the specific leakage points the audit found, not a generic onboarding checklist.
Your existing vendor keeps running while we credential and build claim rules in parallel, proven on real claims first.
Real-time reporting on collections, denials, and A/R velocity, so you see the recovery as it happens, not at quarter-end.
Our local Ohio billing experts identified incorrect behavioral health carve-out submissions and re-routed dual-eligible Next Gen MyCare claims.
See What We Can Recover For YouOhio transitioned all dual-eligible members to the Next Generation MyCare coordinated model administered by Anthem, Buckeye, CareSource, and Molina. Claim routing profiles must be updated for dual enrollees to prevent automatic primary/secondary rejections.
The OhioRISE program routes all pediatric complex behavioral health benefits through Aetna, the single statewide plan. Claims submitted to a member's primary medical MCO instead of Aetna OhioRISE will result in immediate service rejections.
Ohio HB 388 limits out-of-network balance billing for emergency and specific ancillary services, extending to ground ambulance claims. Since it applies only to fully-insured commercial coverage (excluding self-funded ERISA), billing operations must audit plan funding types before initiating dispute resolution.
We check specifically for Next Gen MyCare coordinated dual-eligible structures, OhioRISE Aetna carve-out eligibility, and HB 388 balance-billing rules.
