Intermediate Care Facility Initial Enrollment
Prior to enrolling with Ohio Medicaid, please ensure that your facility has gone through the appropriate licensing process with DODD and the certification process with ODH.
Once you’ve submitted your readiness letter to the Ohio Department of Health, please submit a provider application on the Medicaid Enrollment (MITS) website located here and follow the on-screen prompts.
The following documentation will be required:
- A completed, signed, and dated Request for Taxpayer Identification Number and Certification (W-9)
- A copy of the National Provider Identifier (NPI) assignment notification from the National Plan and Provider Enumeration System (NPPES). The NPI information is required for all ICFs.
- Addendum to ODM 03623 for Intermediate Care Facilities for Individuals with Intellectual Disabilities form completed and signed.
- A copy of the Ohio Department of Developmental Disabilities development approval letter.
- A copy of the facility license issued by the Ohio Department of Developmental Disabilities.
- Documentation of payment of all appropriate enrollment fees to Ohio Medicaid.
An enrollment fee for the Medicaid application will be required during the process, which shall be submitted through the MITS portal.
Once all documentation has been received, screened and approved by the LTC Enrollment Coordinator, you will receive a welcome letter and a copy of your provider agreement. In order to be activated in the MITS system, you will need to sign and return this agreement within 10 business days to the following address:
Ohio Dept. of Medicaid
Bureau of Network Management
Julie Moore, LTC Enrollment
P.O. Box 182709
Columbus, OH 43218-2709
Once this provider agreement has been signed and returned to Ohio Medicaid, you will be fully activated and enrolled in the system.
Intermediate Care Facility Revalidation
Intermediate Care Facilities are required to be revalidated every 5 years. Ninety (90) days prior to the expiration date of your provider agreement, you will receive a notice to revalidate. Within this notice to revalidate, you will receive a revalidation identification number and link to the revalidation starting webpage. Follow the prompts to complete the revalidation.
A revalidation fee is required during this process, please follow the prompts to pay the fee on the MITS portal.
Once the revalidation has been completed by our LTC Enrollment Coordinator, you will receive a Revalidation Confirmation letter along with the provider agreement for your signature. Please return this within 10 days to the following address:
Ohio Dept. of Medicaid
Bureau of Network Management
Julie Moore, LTC Enrollment
P.O. Box 182709
Columbus, OH 43218-2709
Please note: If there is no information regarding owner/managing employee disclosures in the revalidation application, you are required to submit the Provider Revalidation Owner/Managing Employee Disclosure Form. Your Revalidation letter will include this form, please fill this out and return it with your signed provider agreement.