Ohio Home Care Waiver Provider Application Process

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 16 161 Other accredited Home Health Agency 25 250 PCS - Personal Care Services 26 260 Home Care Attendant 38 381 RN 38 383 LPN 45/55 450 Home Meals 45/55 451 Supplemental Transport Services 45/55 452 Adult Day Health 45/55 453 Supplemental Adaptive/Assistive Devices 45/55 455 Home Delivered Meals 45/55 454 Minor Home Modifications 45/55 456 Out of Home Respite 45/55 457 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, 8 th Floor Columbus, Ohio 43215 Fax: 1-614-386-1344 Email: OHProvidermaintenance@pcgus.com

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.