UPDATE: Reconciling October 14 advance payments
Ohio Medicaid will begin recouping advanced provider payments made October 14 that were offered due to connectivity issues between systems. Providers that billed through the portal using direct data entry and received an advance payment will see recoupment on the December 22 payment.
Remittance advices will note the recoupment, distinguishing it from the standard claims payments. The recoupment will continue to offset in future payment cycles until it is recovered in full. Click here for more information.
Ohio Medicaid and Managed Care Organizations
Today, more than 90 percent of Ohio Medicaid members are supported by managed care organizations (MCOs). During the year ahead, ODM will begin implementing a new vision for care; focusing on the individual, a strong partnership among MCOs and the department, and supporting specialization in addressing critical needs.
Prescribers, Pharmacists, and Support Staff – SPBM Web Portal training recording now available
The recorded SPBM Web Portal training is now available for prescribers, pharmacists, and support staff. Viewing this training is important for prescribers, pharmacists, and support staff to learn about the many tools available on both the public facing and secure portal. The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria. The secure portal, which requires log in credentials, provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email.
To access the recordings, please follow the below links:
If you have accessed Gainwell’s Ohio Learning Management System (LMS) previously, please use the same credentials set up during your registration to log in. If you have not, you will need to complete registration for the system to access the recording.
If you have questions, please contact Gainwell Technologies by phone at: 1-833-491-0364 or by email at: OH_MCD_PBM_network@gainwelltechnologies.com.
Provider News & Resources
Policies & Guidelines
Ohio Medicaid policy is developed at the federal and state level. It guides how we operate our programs and how we regulate our providers. This page contains resources for the Ohio Medicaid provider community, including policy and advisory letters, billing guidance, Medicaid forms, research, and reports.
Electronic Visit Verification
Electronic Visit Verification (EVV) is used by caregivers for some home and community based services to document the time services begin and end. The Ohio Department of Medicaid provides an EVV system at no cost to all providers. Agency providers may choose to use an alternate EVV system.
Prior Authorization Requirements
Links to Ohio Medicaid prior authorization requirements for fee-for-service and managed care programs.
Episode-based payments is a part of quality-driven payment innovation programming in Ohio Medicaid.
Comprehensive Primary Care
Ohio CPC is an investment in primary care infrastructure intended to support improved population health outcomes.
Specialized Recovery Services
The Specialized Recovery Services program assists adults with severe and persistent mental illness, certain diagnosed chronic conditions, and those actively waiting on specific transplant lists.
Fee Schedule & Rates
Disclaimer about fee schedule and rates available for providers.
Training presentations, videos, and handouts.
Effective Oct. 1, 2022, providers will utilize the new Provider Network Management Module (PNM) to access the MITS Portal. Through this link, providers will be able to submit and adjust fee-for-service claims, prior authorizations requests, hospice applications, and managed service providers/hospital/long term care cost reports. Providers also will be able to verify recipient eligibility and update trading partner information. For additional information, please visit: https://managedcare.medicaid.ohio.gov/providers
The next generation of Ohio Medicaid managed care is designed to improve wellness and health outcomes, support providers in better patient care, increase transparency and accountability, improve care for children and adults with complex behavioral needs, and emphasize a personalized care experience.
Programs & Initiatives
The Ohio Department of Medicaid has many programs and initiatives to enhance the quality of care for patients and support our providers in the work they do each day.
COVID-19 and Monkeypox
Ohio Department of Medicaid COVID-19 and Monkeypox Resources and Guidelines for Providers
Provider billing and data exchange related instructions, policies, and resources.
Enrollment & Support
Ohio Medicaid is changing the way we do business. We are streamlining provider enrollment and support services to make it easier for you to work with us. Information about provider enrollment and assistance is located here.
Managed Care Procurement
New Medicaid Managed Care contracts to reframe the system of coordinated health care for Medicaid Members.
Provider Network Management (PNM) & Centralized Credentialing
A centralized portal to reduce the administrative burden on providers by streamlining the process for provider certification.
OhioRISE (Resilience through Integrated Systems and Excellence)
A specialized Medicaid managed care plan with tailored services to meet the needs of youth with complex needs.
Ohio Medicaid Single Pharmacy Benefit Manager (SPBM)
A single system to improve management and administration of pharmacy benefits for managed care recipients while decreasing costs for the state.
A single point of entry for all provider claims and prior authorization requests.
Successor Liability Agreements
Model agreement language for use by a nursing facility or intermediate care facility for individuals with intellectual developmental disabilities when closing or executing a change of operator.
Automated Cost Reporting
Policy updates and links to submission instructions for various cost reports.
Home Health Services
Description of home health services, who is eligible to receive them, and requirements for providers, along with related links.
Cost Report, Rate Setting, Case Mix, Prior Authorization FAQs, Fact Sheets, Other Resources.