The Ohio Department of Medicaid (ODM) is launching new initiatives as a part of the Next Generation of Ohio Medicaid program to emphasize a more personalized care experience and increase program transparency and accountability.  

On October 1, ODM is excited to launch Centralized Credentialing in the Provider Network Management (PNM) module and Single Pharmacy Benefit Manager (SPBM) as part of the Next Generation program. These efforts will help reduce administrative burden on providers and provide enhanced pharmacy services across all managed care plans and members.  

The SPBM does 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.  

How can you prepare for the October 1 launch? 

We know that this may seem like a big change for you, so we wanted to provide you with some resources and tips for how to prepare yourself for this launch.   

The Ohio Department of Medicaid (ODM) is excited to announce that the Provider Network Management (PNM) module is going live on October 1! The PNM module serves as the single-entry point for secure portal functions such as claims submissions, prior authorizations, and member eligibility verification. Beginning October 1, until December 1, providers are redirected from the PNM module to the appropriate MITS functionality.

As a reminder, ODM, the Ohio Department of Developmental Disabilities (DODD), and the Ohio Department of Aging (ODA) have implemented this new system to replace the current MITS Provider Enrollment subsystem and MITS Provider portal.

What actions will I need to take? 

1. An OH|ID is required for providers to access the PNM module. If you do not have an existing OH|ID, you will need to create one to access the PNM module.  
   • Access the PNM module by clicking here.
   • Click on the “Don't Have An Account Click Here” link on the PNM homepage. You will be redirected to the OH|ID site to create your new account. 
2. If you have an OH|ID or once you have created one, use your new OH|ID to log in to the PNM module by clicking here. You can also access the PNM module through a link on the PNM & Centralized Credentialing page of ODM’s Next Generation website. 
3. Setup your Administrator & Agent roles in the PNM module. Remember, these will need to be re-established in the PNM module. For more information, access the Agent Assignment & Actions Quick Reference Guide. 
4. You are now able to access the features and functionality available in the PNM module, including managing provider data via self-service functionality, submitting new enrollment applications, verifying member eligibility, and submitting fee-for-service claims and prior authorizations. 

What does this change mean to me? 

 The PNM will allow providers to submit a single Ohio Medicaid enrollment and credentialing application, simplifying and streamlining administrative activities for providers. Providers will still contract separately with Ohio Medicaid MCOs. The PNM provides a single entry-point for enrollment, revalidations, and credentialing, and more. 

For technical support 

If you need assistance or experience technical issues, contact the ODM Integrated Help Desk at 1-800-686-1516 or email the ODM Integrated Help Desk at IHD@medicaid.ohio.gov for assistance with OH|ID or portal password support.  

Additional resources 

Additional resources can be accessed by clicking on the appropriate links below:

• Training materials

• PNM Frequently Asked Questions (FAQ) 

For more information  

To learn more about the PNM module and Centralized Credentialing, visit the PNM & Centralized Credentialing page of ODM’s Next Generation website.

The Ohio Department of Medicaid (ODM), in partnership with Gainwell Technologies, is launching the Single Pharmacy Benefit Manager (SPBM) on October 1. ODM’s goals for SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through SPBM, ODM will gain increased accountability and ensure alignment with clinical and policy goals, while also improving transparency. Pharmacies must be enrolled with ODM to contract with Gainwell and provide pharmacy services to members. With the SPBM, pharmacists and prescribers will see benefits from streamlining and consolidating of processes currently provided by multiple, individually contracted PBMs. Below are ways you can help to support the transition to the SPBM on October 1, and beyond, with links to available resources. 

1. Watch the SPBM portal training videos. 
   • Pharmacists, pharmacy support staff, prescribers, prescriber support staff, and managed care entity (MCE) portal administrators and staff attended SPBM portal training. These sessions provided details about the tools available on the SPBM portal such as member eligibility verification, prior authorization submission for prescribers, the ability to quickly chat with the SPBM help desk, and much more! 
   • The recordings of these training are available, here.  
2. Access and review the SPBM provider manual. 
   • Gainwell’s SPBM provider manual, also known as the pharmacy reference guide, is the primary resource guide providing key information to pharmacists, pharmacy support staff, prescribers, and prescriber support staff. 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. 
   • The provider manual can be found on ODM’s Next Generation website under, “Provider Manual.” The provider manual is updated periodically to reflect program changes or clarifications as necessary. 
3. Review resources related to specialty pharmacy information. 
   • Gainwell will be responsible for managing pharmacy services, including a specialty pharmacy program, for all Medicaid managed care members. This does not include MyCare Ohio. 
   • Specialty pharmacy information, including specialty pharmacy contracting, specialty pharmacy reimbursement, and the specialty pharmacy drug list can be found on the Resources for Pharmacists and Pharmacy Support Staff webpage, under the “Specialty Pharmacy Information” tab. 
4. Familiarize yourself with the Next Generation member ID cards. 
   • Pharmacists and pharmacy support staff should be aware that all Ohio Medicaid managed care members will receive a new member ID card in the mail prior to October 1, 2022, from their MCO. This does not include members enrolled in a MyCare Ohio plan. This new card will reflect that, beginning October 1, pharmacy benefits for members enrolled in managed care will be covered by Gainwell. Pharmacy benefits will no longer be provided by the MCOs.  
   • Please continue to bill pharmacy services to the member’s original assigned payer, the MCO PBM, – until October 1. Reversals for claims originally billed before October 1 should be also sent to the original payer. 
   • If presented with a Next Generation identification card before October 1, 2022, verify coverage in the Medicaid Information Technology System (MITS) and bill pharmacy services to the member’s assigned payer (FFS or MCO). 

After October 1, Gainwell should receive pharmacy claims for managed care members. Claims for fee-for-service members will continue to be submitted to the fee-for-service Pharmacy Benefit Administrator (PBA), Change Healthcare. If a member does not have a Medicaid ID card, a pharmacy can verify coverage in MITS with the member’s demographic information. To bill Gainwell, the pharmacy will need the following information: 

• Gainwell RxBIN: 024251 
• Gainwell RxPCN: OHRXPROD (note: Gainwell does not require a group number) 
• Ohio 12-digit Medicaid Member ID (formerly called the MMIS ID). Gainwell will NOT accept a secondary “Member ID” assigned by the managed care plans. 

• Options to access a Medicaid Member ID include viewing the MMIS located on the ID card or digital ID card via the MCO website or app, logging in to the SPBM secure web portal and searching for the member at https://spbm.medicaid.ohio.gov, query Surescripts against Gainwell’s master patient index, or searching in MITS.