Home care billing in Ohio

Key facts for Ohio home care billing

Programs that pay for home care in Ohio¹

• Ohio Home Care Waiver (0337.R06.00)

  Personal care aide, home care attendant, waiver nursing, out-of-home respite, adult day health center services, home delivered meals, home maintenance and chore, home modification, personal emergency response systems, self-directed goods and services, structured family caregiving, supplemental adaptive and assistive devices, supplemental transportation and vehicle modification

  For individuals with physical disabilities ages 0 to 59 who meet a hospital or nursing facility level of care.

• PASSPORT Waiver (0198.R07.00)

  Homemaker, personal care, home care attendant, choices home care attendant, waiver nursing, adult day service, alternative meals, home delivered meals, home maintenance and chore, home medical equipment and supplies, home modification, non-medical transportation, nutritional consultation, out-of-home respite, personal emergency response system, social work counseling, structured family caregiving, community integration and community transition

  For individuals ages 65 or older and individuals with physical disabilities ages 60 to 64 who meet a nursing facility level of care.

• MyCare Ohio Waiver (1035.R02.00)

  Homemaker, personal care, home care attendant, waiver nursing, adult day health, assisted living service, enhanced community living, home delivered meals, home modification, out-of-home respite, personal emergency response system, social work counseling, structured family caregiving and waiver transportation

  For individuals ages 65 or older and individuals with physical disabilities ages 21 to 64 who meet a hospital or nursing facility level of care. The waiver operates with concurrent 1915(b)(1) and 1915(b)(4) authority, which is what makes MyCare a managed care program.

• Assisted Living Waiver (0446.R04.00)

  Assisted living services and community transition services

  For individuals with physical disabilities ages 21 to 64 and individuals ages 65 or older who meet a nursing facility level of care.

• DODD waivers, Individual Options (0231.R06.00), Level One (0380.R05.00) and SELF (0877.R03.00)

  Homemaker/personal care, participant-directed homemaker/personal care, waiver nursing (Individual Options) or waiver nursing delegation, residential and community respite, adult day support, home delivered meals, non-medical transportation, remote supports and related habilitation and employment supports

  For individuals with intellectual or developmental disabilities ages 0 or older who meet an ICF/IID level of care.

Common rejections in Ohio, and the fix

• Claim denied with no matching EVV visit in the Sandata Aggregator

  The fixSince March 1, 2025 the payer asks the aggregator for a match at billing and denies the claim if none is found. The biller checks the aggregator before the batch leaves: the visit must be there, verified, for the right recipient, provider, service and date. For an alternate vendor the External ID on the aggregator visit is the VisitOtherID your vendor sent, so a visit that never left your system never reached the aggregator. Fix the visit first, then rebill.

• Visit rejected because the payer left the program

  The fixAetna visits with dates of service after December 31, 2025 for any EVV program, and UnitedHealthcare MyCare visits after that date, are rejected by Sandata. Anthem MyCare codes took effect January 1, 2026. The biller keeps the payer and program tables in the agency's EVV system and practice management system current for 2026 dates of service, so no visit goes to a payer that has left the program.

• MyCare claim sent to the plan's old address after January 1, 2026

  The fixFrom January 1, 2026 all EDI Next Generation MyCare claims, regardless of date of service, go through ODM's One Front Door and are forwarded by the Receiver ID in the header and the Payer ID in loop 2010BB NM109; the cut-over was hard. Members in the 29 original MyCare counties moved first and ODM's schedule added the remaining counties monthly from April to August 2026, so the biller reads each MyCare member's current plan before building the claim.

• Home health or private duty nursing authorization cut off at 60 days

  The fixThe ODM provider agreement bars a Next Generation MCO from applying a hard 60-calendar-day limit to a home health or PDN authorization period; it must size the period to the member's needs and reflect it in the person-centered care plan. When a plan issues a short authorization for a stable, chronic condition, the biller asks the plan to reconsider the period under the agreement rather than filing a new request every two months, and confirms state plan home health was used before a similar waiver service.

• Fee-for-service claim filed after the 365-day window

  The fixODM allows 365 days from the date of service. A denied claim that was received on time may be resubmitted within 180 days of the denial under OAC 5160-1-19(C)(2)(ii), so the biller works denials against the denial date, not the service date, and files each verified waiver visit before the 365-day window closes.

• Call-time adjustment rejected by Sandata

  The fixSandata rejects an adjustment message when the adjusted timeframe does not overlap the originally reported call times of the initial visit. The caregiver's original clock-in and clock-out have to stand as the anchor; a correction that moves the whole visit to a different window needs the visit re-entered through the vendor's own process, and the biller holds the claim until the aggregator shows the corrected visit.

• Direct-entry claim keyed into the wrong system

  The fixA fee-for-service claim or prior authorization keyed by hand starts in the PNM module and redirects to MITS; a managed care claim or prior authorization goes into that plan's own portal. The biller checks the member's enrollment in PNM first, because the same visit for a MyCare member and for a fee-for-service PASSPORT member has two different doors.