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Aetna and ODM Clarify OhioRISE Practitioner Modifier Requirements

In preparation for the launch of OhioRISE, the Ohio Department of Medicaid (ODM) and Aetna have made some changes to clarify Aetna’s practitioner modifier requirements for professional and outpatient claims.

With the implementation of this update in Aetna’s billing requirements, Aetna will not require the previously announced practitioner modifiers on the following types of claims (unless the rendering practitioner holds multiple licenses or credentials with differing scope of practice):

  • Community mental health agency claims (provider type 84).

  • Community substance use disorder treatment provider claims (provider type 95).

  • OhioRISE care management entity (CME) claims.

  • Other professional and behavioral health services are reimbursed in accordance with Appendix DD of Ohio Administrative Code (OAC) rule 5160-1-60 (this includes BH services rendered by providers other than community MH/SUD agencies).

  • Outpatient hospital claims submitted for Enhanced Ambulatory Patient Groups (EAPG) reimbursement.

In alignment with ODM fee-for-service policy, Aetna will require practitioner modifiers on outpatient hospital claims submitted for Outpatient Hospital Behavioral Health (OPHBH) reimbursement. Aetna’s OPHBH practitioner modifier requirements will mirror ODM’s fee-for-service requirements.

Until Aetna is able to reconfigure its claims engine to incorporate these changes, they will need to process some claims manually. However, providers will not be required to resubmit or adjust claims at a later date if their claims are processed manually because of Aetna’s reconfiguration timeline.


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