Important reminder: Update addresses and affiliations in the Provider Network Management (PNM) module.
It is imperative that providers update all address and affiliation information in the PNM so that claims payments, provider directories, and network adequacy measurements are not negatively impacted.
Click on the following links for step-by-step instructions on how to complete these actions.
- Updating or Adding Owner Information
- Updating or Adding Practice Locations
- Updating or Adding a Specialty in PNM
View trading partner connectivity status
Over the last several months, Ohio Department of Medicaid (ODM) has partnered with providers and trading partners to connect them to the new Electronic Data Interchange to facilitate accurate and timely claims submission. Providers can check their trading partner connectivity status by viewing this easy-to-use spreadsheet of all known ODM trading partners. This information is updated regularly.
Important: Provider Network Management affiliation steps are not complete and may impact provider billing
Through a series of Provider Network Management (PNM) queries, Ohio Department of Medicaid (ODM) has identified several affiliation issues that impact billing organizations claims. It is imperative that providers fully execute all steps when affiliating a rendering provider to their group/organization/hospital to avoid claims payment issues. ODM has identified that providers tend to leave affiliations in one of two incomplete statuses:
- Pending Approval.
- Confirmed.
A provider affiliation can be initiated and completed by the group/organization/hospital, or it can be initiated through the rendering practitioner. If the affiliation is initiated through the rendering individual, it is not complete and remains in a “Pending Approval” status until the group/organization/hospital accepts and saves the affiliation. At that point it will appear “Confirmed.” For the provider affiliation to be sent downstream and receive an “Active” status, there are two remaining critical steps:
- Click “Save” at the top of the page to save all the updates. Once saved, the user will have a new “Submit for Review” button appear.
- Click “Submit for Review.” Users must click on this button to complete the process and submit the affiliations downstream. Affiliations are fully executed only once this final step has been taken.
If these steps are not completed, the provider affiliation is not sent downstream, and providers will experience claims payment issues.
For more information
The PNM Learning tab includes step-by-step instructions in three quick reference guides (QRG) under “Existing Users” for affiliation assistance. These are titled “Adding a Group Affiliation,” “Adding a Hospital Affiliation,” and “Affiliations.”
Providers wanting to view or edit a claim must use the same system that was used for the original submission
These systems include managed care entity (MCE) portals, the MITS page accessed via the PNM module, or through an authorized trading partner utilizing the new EDI portal. For example, if a provider submits a claim via an MCE portal, the provider must then use the same MCE portal to view or edit their claim. Claims submitted via trading partners are not viewable within the PNM module; however, providers can work with their trading partner to view a claim status.
Getting help with Provider Network Management module issues and questions
Resources on the PNM and Centralized Credentialing page are available to assist you in resolving the most common issues providers are experiencing.
Prescribers, pharmacists, and support staff: Single Pharmacy Benefit Manager web portal training now available
The recorded Single Pharmacy Benefit Manager (SPBM) web portal training is now available. Viewing this 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 (UPDL) and criteria. The secure portal, which requires login credentials, provides access to specific patient information and the ability to reach the SPBM clinical helpdesk via web chat. SPBM clinical staff can also be reached via phone and email.
Access the training for prescribers, pharmacists, and support staff.
If you have accessed Gainwell’s Ohio learning management system (LMS) previously, please use the same credentials set up during your initial 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 at 1-833-491-0364 or OH_MCD_PBM_network@gainwelltechnologies.com.
Popular Resources
Welcome Providers
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.
Episodes of Care Announcements
Program Communications from ODM
Episode-based Payments
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
Training presentations, videos, and handouts.
MITS
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
Managed Care
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 Mpox
Ohio Department of Medicaid COVID-19 and Mpox Resources and Guidelines for Providers
Billing
Provider billing and data exchange related instructions, policies, and resources.
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.
Fiscal Intermediary
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.
Nursing Facilities
Cost Report, Rate Setting, Case Mix, Prior Authorization FAQs, Fact Sheets, Other Resources.
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.