We are aware that there is an issue when accessing MITS through the Provider Network Management module and are working quickly to resolve this issue. Thank you for your patience during this time.

On October 1, the Ohio Department of Medicaid (ODM) launched Centralized Credentialing in the Provider Network Management (PNM) module and Single Pharmacy Benefit Manager (SPBM) as part of the Next Generation of Ohio Medicaid program. Through this launch, ODM has helped reduce administrative burden on providers.   

The Next Generation managed care program 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.  

What can providers expect with the launch of Centralized Credentialing and PNM? 

• Providers subject to credentialing can be credentialed just once at the state level versus a separate credentialing process for each Ohio Medicaid managed care plan. 
• There is no longer a need for paper agreements at long-term care facilities – all agreements are available online and do not require mailing back and forth for signatures. 
• Providers now can view specialties and effective dates. 

The Ohio Department of Medicaid (ODM) is excited to announce that the Provider Network Management (PNM) module went 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 does this change mean to me? 

The PNM allows 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) 

The Ohio Department of Medicaid (ODM) and Gainwell Technologies launched the Single Pharmacy Benefit Manager (SPBM) on October 1. ODM’s goals for the SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through the SPBM, ODM gains increased accountability and ensures 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 see benefits from streamlining and consolidating of processes currently provided by multiple, individually contracted PBMs. Below are ways you can help support the transition to the SPBM beyond October 1, 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 is responsible for managing pharmacy services, including a specialty pharmacy program, for Medicaid managed care members. This does not include members enrolled in a MyCare Ohio plan. 
   • Specialty pharmacy information, including specialty pharmacy contracting, specialty pharmacy reimbursement, and the specialty pharmacy drug list can be found no the Resources for Pharmacists and Pharmacy Support Staff webpage, under “Specialty Pharmacy Information”. 
4. Familiarize yourself with the Next Generation member ID cards. 
   • Pharmacists and pharmacy support staff should be aware that Ohio Medicaid managed care members received a new member ID card in the mail from their MCO. (This does not include members enrolled in a MyCare Ohio plan.) This new card reflects that pharmacy benefits for members enrolled in managed care are covered by Gainwell. Pharmacy benefits are no longer provided by the MCOs.  
   • Pharmacy services will now be billed to Gainwell, beginning October 1. Reversals for claims originally billed before October 1 should be 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).

Going forward, Gainwell should receive pharmacy claims for managed care members. This does not include member enrolled in a MyCare Ohio plan. Claims for fee-for-service (FFS) members will continue to be submitted to the FFS Pharmacy Benefit Administrator, 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 needs 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.
• What does the Next Generation managed care identification card look like?