Transcript Ohio Provider Enrollment Application - Provider Oversight

Ohio Home Care Waiver Provider
Application Process
Provider Enrollment Website
medicaid.ohio.gov
Hover over the Providers Tab
Hover over Enrollment and Support
Click Provider Enrollment
On the next page, click
“Enroll as a New Provider”
On this page, you will also find required application
documents and a link to the MITS portal, located in
the right margin as you scroll down the page.
After clicking ‘Enroll as a New Provider’, click
‘I need to enroll as a provider to bill Ohio Medicaid’
Even if you are a previous provider
and wish to re-enroll, a new
application is needed.
This will expand the Instructions box. Click ‘new application’
or ‘continue application’ in the lower right corner. ‘Continue
application’ will resume an application in progress.
Application Page 2: Request Type
Application Page 2, Continued
Select an enrollment type, either individual practitioner or
organization. Please note that individuals should enroll as
individual practitioners and not as organizations.
Application Page 2, Continued
Choose the provider type for which you are
applying.
Application Page 2, Continued
If you are a re-enrolling provider, select ‘No’ for the
question ‘Are you a provider new to Ohio Medicaid?’
and enter your 7- digit Medicaid number. If you are a
new provider, select ‘Yes’.
Application Page 3: Identifying Information.
Applicants will enter Identifying Information. Only
fields marked with a * are required.
Application Fee for Agency Providers
Agency providers will be prompted to pay an application fee.
The fee is paid with the initial application and every 5 years at
revalidation.
• Applicants will receive a confirmation number for the fee.
This number must be entered in the Confirmation Number
field at the bottom of the page.
• If the agency is a Medicare/Medicaid provider, and has paid
the fee in the last 5years, answer ‘YES’ to the Medicare or
Medicaid application fee question and submit proof of
payment with the application.
Application Fee for Agency Providers, Continued
Application Page 4: Tax Information
On page 4, an ATN is assigned and tax information
is needed. The IRS effective date should be today’s
date. The IRS end date auto-fills.
Application Page 4, Continued
W-9 should be marked ‘YES’. Form 147 will
be marked ‘NO’ for individuals. Organizations
that need Form 147 will check ‘YES’.
Application Page 5: DEA License
This page requests DEA license information to
administer drugs. Most applicants will not have a
license to administer drugs and can click next.
Application Page 6: Address Information
The Address Type needs to be
practice location or the applicant
will not be able to continue.
Application Page 7: Type and Specialty
This page will auto fill for individuals. The primary
specialty box needs to be checked. Organizations may
pick other specialties using the drop down options.
Provider Type & Specialties
TYPE
SPECIALITY
DESCRIPTION
16
25
26
38
38
45/55
45/55
45/55
45/55
45/55
45/55
45/55
45/55
161
250
260
381
383
450
451
452
453
455
454
456
457
Other accredited Home Health Agency
PCS - Personal Care Services
Home Care Attendant
RN
LPN
Home Meals
Supplemental Transport Services
Adult Day Health
Supplemental Adaptive/Assistive Devices
Home Delivered Meals
Minor Home Modifications
Out of Home Respite
Emergency Response System
60
601
Medicare Certified Home Health Agency
Application Page 8: Language
Applicants may add any additional
languages they speak.
Application Page 9: Group Affiliations
Applicants affiliated with a group practice or
practices would click add and fill in the information
on this page. Most applicants will leave this page
blank.
Application Page 10: Criminal Offense I
Disclose convictions here.
Application Page 11: Criminal Offense II
Disclose convictions here.
Application Page 12: Violations of State or Federal Law
Disclose violations of State or Federal Law.
Application Page 13: Previously Participated
For re-enrolling providers, that previously had a
Medicaid provider number, click yes and enter the
previous provider ID.
Application Page 14: Medicare Sanctions
Any sanctions by the Medicare program
must be entered.
Application Page 15: Addendum E
To proceed all questions must be answered yes
with the exception of the residency questions.
Application Page 15: Addendum E, Continued
For LPNs, an RN supervisor’s name and license
number is needed.
Application Page 15: Addendum E, Continued
Relationship to consumer: Check ‘YES’ to indicate you meet
the requirements to be the provider for the individual you will
be providing services to. The provider cannot be the legally
responsible family member.
Legally responsible family members include
• Spouse
• Birth or adoptive parent (in the case of a minor)
• Foster caregiver
Application Page 15: Addendum E, Continued
Check yes or no for each residency question. Applicants
that have not been an Ohio resident for at least the last five
years will need an FBI check in addition to a BCI
background check to process the application.
Application Page 15: Addendum E, Continued
The applicant must type an electronic signature
at the bottom of the page.
Application Page 16: Certification
Fill in Legal Entity Name and Individual Name.
The primary practice address also needs to be
completed. The Enrollment Checklist link
provides a list of documents needed to complete
the application.
Application Page 16: Certification, Continued
All applicants must read and accept
the terms. Use the scroll bar on the
right of each section to read the
terms and select ‘I accept the terms
and conditions.’
Application Page 16: Certification, Continued
Check the provision check box and sign at
the bottom.
Application Page 17: Documents Submission Type and Notes
Applicants will choose mail or upload for application
documents and add any comments they feel are helpful. Click
‘submit’ at the bottom of the page to submit the application.
Application Page 18: Confirmation of Receipt
A list of required documents will come up with
address to send to. There are also links to upload
documents and print the application.
Application Page 18: Confirmation of Receipt, Continued
Note: the address on application is incorrect.
Please Mail Documents To:
Public Consulting Group
Home and Community-Based Provider Oversight
Services
155 East Broad Street, 8th Floor
Columbus, Ohio 43215
Fax: 1-614-386-1344
Email: [email protected]
Please Have Background Check Mailed to:
Ohio Department of Medicaid
Attn: BCI Coordinator
PO Box 183017
Columbus, OH 43218
Uploading Documents after the
Application Is Submitted
Go to the provider enrollment page and click
“Check Provider Enrollment Status”
This will bring up a new page where applicants will
enter the ATN assigned to the application and their last
name. The last name must be in CAPS.
Applicants can check application and document
status. At the bottom of the page, applicants
can use the link to upload documents.
Click ‘Upload required documents’ to upload new
documents. Select the document type to upload and
browse to select the document being uploaded.