Nursing Facility Initial Enrollment

To begin enrollment in Ohio Medicaid, please ensure that your Nursing Facility has gone through the appropriate approval process from the Ohio Department of Health. Click here for guidance on the ODH process.

Once you have 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 documents are required to be submitted with the application for initial enrollment:

• CMS 671 Long Term Care Facility Application for Medicare and Medicaid
• 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 NFs.
• A copy of the certificate of need approved by the Ohio Department of Health.
• A copy of the facility license issued by the Ohio Department of Health.
• Documentation of payment to CMS of all appropriate enrollment fees (if fees are not paid through CMS, payment can be remitted through the MITS portal for Medicaid).
• In accordance with Ohio Revised Code 5165.07 (C)(3), a copy of the current lease agreement(s) that specifies the property owner(s) and parties responsible for payment of real estate and commercial activity tax (CAT).
• Pursuant to 42 CFR 483.73 and Ohio Administrative Code 5160-3-02.7(C), a copy of your most recent written emergency plan so that ODM may ensure your compliance with this requirement.

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:

Once this provider agreement has been signed and returned to Ohio Medicaid, you will be fully activated and enrolled in the system.

Revalidation

Nursing 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.

Your revalidation fee will be paid to CMS upon your Medicare revalidation.

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:

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. Please ensure that this information matches what has been supplied to the Centers for Medicare & Medicaid Services.

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:

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:

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.

Per the Provider Agreement, you are required to notify ODM of a facility closure 90 days prior to the date the facility will cease operations.

Once this has been received, ODM will send a letter of acknowledgement with instructions and a list of additional documentation needed. Once the final closure has been completed, the following information must be submitted:

• Exiting Information and Forwarding Instructions from Long-Term Care Facility Operators/Providers Discontinuing Participation in the Ohio Medicaid Program form
• The date of closure
• The names and Medicaid numbers of the residents transferred
• Their transfer dates, if different than that date of closure
• The location of their transfers
• A copy of the written notice given to the residents of the facility and their sponsors
• Future use of the building and the beds

Please send this information to the following address, to finalize the closure with ODM:

In the event of a Change of Operator, the Ohio Department of Medicaid must be notified in writing at least 45 days prior to the date of the change. There are several documents required from both the exiting and entering operators:

The Entering Operator is required to submit:

• A completed, signed, and dated Request for Taxpayer Identification Number and Certification
• A copy of the National Provider Identifier (NPI) assignment notification from the National Plan and Provider Enumeration System (NPPES). If the entering operator is assuming the exiting operator’s NPI, a copy of the correspondence from NPPES confirmed the transfer.
• Enrollment application through the MITS portal

The Exiting Operator is required to submit:

• A completed, signed, and dated “Exiting Information and Forwarding Instructions from Long-Term Care Facility Operators/Providers (NFs and ICFs) Discontinuing Participation in the Ohio Medicaid Program
• One completed, signed, and dated Request for Taxpayer Identification Number and Certification.

Both Entering and Exiting Operator/Owner are jointly responsible for providing the following items:

• Copies of all final and fully executed documents for the transaction culminating in the CHOP. This includes sales agreements, leases, assignments of leases, merger agreements, and any other applicable documents.
• 45-day notice (in writing)

When the 45-day notice has been received, a CHOP acknowledgement letter will be sent, with instructions on next steps.

Once all relevant information has been received through the MITS Portal, you will receive your paper copy of the provider agreement. Please sign and return the provider agreement within 10 days, and mail back to the following address:

Once this has been received at the Ohio Department of Medicaid, your new Medicaid ID Number will be activated in our MITS system.

Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for Individuals with Intellectual Disabilities

Revalidation of Provider Agreements

Medicaid Coverage of Nursing Facility Services

Intermediate Care Facility for Individuals with Intellectual Disabilities Services

Notice of Change of Operator - Nursing Facilities

Notice of Change of Operator - ICFs

Provider Screening and Application fee