There is just one week remaining of the Provider Network Management (PNM) pre-registration period. Providers have until Friday, September 23, to pre-register for the PNM module ahead of the PNM launch on October 1. As a reminder, an OH|ID is required to access the PNM module. Access to key administrative functions could be delayed for providers who do not pre-register. If providers are unable to take advantage of pre-registration, they will still be able to access the PNM and setup their account at go-live October 1. |
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If providers need technical assistance or encounter an error while pre-registering, please direct them to contact the ODM Integrated Help Desk Command Center at 1-800-686-1516, option 8. For more information on PNM pre-registration or the PNM module, please visit the PNM & Centralized Credentialing page on the ODM Managed Care site.
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Beginning October 1, pharmacy benefits for managed Medicaid members will be covered by the Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies. Gainwell’s provider manual, also known as the pharmacy reference guide, is the primary resource guide providing key information to pharmacy providers, pharmacy support staff, and prescribers. The provider manual includes information related to pharmacy claims submission, reimbursement rates, pharmacy network requirements, the specialty pharmacy program, claims processing, utilization management, and prior authorization.
How Do I Access the SPBM Provider Manual?
The provider manual can be found here and on ODM’s Next Generation website under Provider Manual. The provider manual is updated periodically to reflect program changes or clarifications as necessary.
For additional information about SPBM please visit ODM’s Next Generation website or the Gainwell Ohio Pharmacy website.
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The Gainwell Ohio SPBM training staff would like to remind pharmacists, and pharmacy support staff that it is not too late to register for SPBM Web Portal training!
Please join us to learn the difference between the public and the secure portals, including how to register for the latter. The public facing SPBM Web Portal provides instant access to reference material such as the Unified Preferred Drug list (UPDL) and criteria, the Preferred Diabetic Supply list, the Specialty Drug list, and Quantity Limits list to assist with prescribing medications to Ohio Medicaid Managed Care members.
The secure SPBM Web Portal requires credentials which provides a way for users to check eligibility of Ohio Medicaid managed care members, the ability for prescribers and designated support staff to submit prior authorizations, the ability for pharmacies to submit claims, users to view claim and prior authorization history, and a secure web chat to quickly speak with the SPBM help desk.
Registration instructions can be found by navigating to https://spbm.medicaid.ohio.gov and selecting the provider tab. Under the provider tab, you will find the associated menu for “SPBM Web Portal Training.” Training begins September 19 for pharmacists and pharmacy support staff.
If you are unable to attend one of the live instructor-led webinars, it is still important to register for the Gainwell Ohio Learning Management System (LMS) so that you will have access to the recorded training. Once the recorded training is available on the Gainwell Ohio LMS, an announcement will be placed in the “Announcement” area of the SPBM web portal’s home page.
If you have any questions regarding SPBM web portal training, please email OH_MCD_PBM@gainwelltechnologies.com.
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As you are likely aware, Ohio Medicaid is in the process of implementing our Next Generation program to focus on the individual rather than the business of managed care so that we can do better for the people we serve. One way we hope to achieve this vision is through the implementation of the Provider Network Management (PNM) module to reduce the administrative burden on providers.
Training and Learning Management System
In preparation for Stage 2 go-live (October 1, 2022), we are offering a variety of training options including self-paced, virtual, and in-person training options. Absorb, the Learning Management System (LMS), is where you will access the self-paced training and sign up for the virtual and/or in-person sessions.
LMS Registration
It is important that you create an account in the LMS to ensure you have access to all training sessions, answer forms, and PNM resources in advance. Click on the appropriate link below, based on your provider type, to access the LMS and follow the steps to create your account and register for training:
Questions
Please email OhioTrainingTeam@maximus.com with any questions regarding training sessions or additional information.
About the PNM and Centralized Credentialing
The PNM module and Centralized Credentialing program are part of the “Big 5” strategic initiatives being implemented within the Next Generation of Ohio Medicaid’s managed care program.
The PNM will replace the current Medicaid Information Technology System (MITS) provider enrollment subsystem provider portal. This module will be implemented along with Centralized Credentialing, which is a state-level single centralized provider credentialing process. These initiatives will modernize the system by streamlining processes and reducing administrative burdens for providers. For more information about PNM and Centralized Credentialing, visit the Managed Care website.
Thank you in advance for your consideration and for your support of ODM’s Next Generation vision.
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Important changes that may impact you as an Ohio Medicaid (ODM), Department of Developmental Disabilities (DODD), or Ohio Department of Aging (ODA) provider are coming, and we want to make sure you’re aware of them.
The Ohio Department of Medicaid (ODM) has temporarily paused all provider enrollment and maintenance activities during this transition. On October 1, provider enrollment and maintenance-related activities will resume and be submitted using PNM. Organizational or individual practitioners who will provide services covered by the OhioRISE program and behavioral health community providers may enroll with Medicaid and add OhioRISE provider specialties between August 1 and September 30 to begin providing and billing for services. The guidance was updated on August 31, please view the Updated Community BH and OhioRISE Provider Enrollment During System Transition for direction on this process.
For more information visit:
Send questions to:
For providers certified by DODD, please click here to learn more and view important cut-off dates. For more information visit: www.dodd.ohio.gov
Send questions regarding provider certification to:
For providers certified by ODA, please click here to learn more. For more information visit: www.aging.ohio.gov/certification-changes
Send ODA provider certification questions to:
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On December 1, Ohio Medicaid’s managed care program will change for the better! The Ohio Department of Medicaid (ODM) is introducing its Next Generation managed care plans to focus on the individual, honor members’ choice, and provide continuity in the provision of members’ care.
The Next Generation managed care plan changes do not apply to MyCare Ohio plans, which will continue to provide benefits to Ohioans who receive both Medicaid and Medicare benefits, with enhanced coordination of medical, behavioral, and long-term care services.
The Next Generation of Ohio Medicaid program will be implemented in stages to avoid unnecessary disruption and confusion for members and to reduce burdens on our service providers. After the implementation of OhioRISE on July 1 and Centralized Credentialing and the Single Pharmacy Benefit Manager on October 1, the Next Generation managed care plans will be implemented on December 1 to provide a more personalized approach to supporting Ohio Medicaid members’ healthcare needs.
How can I ensure I don’t lose coverage?
In the coming months, Ohio Medicaid members will receive many communications about their healthcare coverage. It is incredibly important for you to ensure your contact information is up to date. Additionally, please carefully review all communications shared by ODM and follow the instructions provided to ensure continuity of coverage. Learn more here.
What actions are Ohio Medicaid managed care members encouraged to take to select a plan?
Ohio Medicaid encourages you to review the Next Generation plans available and select the plan that best meets your healthcare needs. Current Ohio Medicaid managed care members who do not select a plan will stay with their current plan, with the exception of Paramount members. Paramount Advantage Medicaid has been acquired by Anthem Blue Cross and Blue Shield (Anthem).
Anthem is working with Paramount Advantage to continue providing your healthcare coverage and you will continue receiving healthcare coverage through Paramount Advantage until the Next Generation managed care plans begin providing healthcare coverage. At that time Anthem will be your Next Generation managed care plan. You do not need to take any action to begin receiving healthcare benefits through Anthem and there will be no disruption in your care. All Ohio Medicaid managed care members can select a different plan at any time until the end of open enrollment through November 30.
What does this mean for current Ohio Medicaid managed care members who are also enrolled in the OhioRISE program?
OhioRISE enrollees will receive their behavioral health benefits through Aetna (the OhioRISE plan) and their physical health services through a separate managed care organizations or fee-for-service Medicaid.
How can an Ohio Medicaid managed care member select a Next Generation plan?
Managed care members can review their options using information in communications distributed by Ohio Medicaid and housed on the Medicaid Consumer website at https://www.ohiomh.com. Managed care members may select their plan at any time through November 30 by contacting the Ohio Medicaid Consumer Hotline at (800) 324-8680 or through the online portal at https://members.ohiomh.com.
What resources are available to Ohio Medicaid managed care members to help them identify which Next Generation plan best meets their healthcare needs?
The Next Generation Health Plan Comparison document is available on https://www.ohiomh.com and provides an overview of the services that all Next Generation managed care plans provide, and specific value-added services provided by each individual plan.
The Find A Provider search tool can help members identify which Next Generation managed care plans their trusted providers are contracted – or “in network” – with.
Each Next Generation managed care organization (MCO) has a member website that members can visit to learn more about that MCO’s Next Generation of Ohio Medicaid plan and their approach to serving Ohio Medicaid managed care members:
Members can call the Medicaid Consumer Hotline at (800) 324-8680 if they have additional questions about the Next Generation managed care plan options available.
The Ohio Medicaid Managed Care Member FAQ is available on https://www.ohiomh.com and answers questions related to member transition and provides background about Ohio Medicaid’s Next Generation program.
Next Generation Plan Selection Micro Videos provide information and answers questions related to the transition to the Next Generation managed care plans.
When do Ohio Medicaid managed care members need to select a plan?
Ohio Medicaid managed care members can select a Next Generation plan – or select to stay with their current plan – at any time through November 30. To make a Next Generation plan selection, Ohio Medicaid managed care members can either visit the Ohio Medicaid Consumer Hotline Portal at https://members.ohiomh.com or contact the Ohio Medicaid Consumer Hotline at (800) 324-8680.
When will Ohio Medicaid managed care members begin receiving services from their selected plan?
Ohio Medicaid managed care members will remain with their current managed care plan until Ohio Medicaid's Next Generation managed care plans begin providing healthcare coverage on December 1.
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