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PNM & Centralized Credentialing

PNM & Centralized Credentialing

IMPORTANT UPDATE: Ohio Medicaid is upgrading its provider enrollment system

Effective August 1, 2022, ODM will not be accepting new provider enrollment applications or continue any in-progress enrollment applications through the MITS Provider Enrollment System. Due to the July 1, 2022, launch of the OhioRISE program, organizational or individual practitioners who will be providing services covered by the OhioRISE program may enroll with Medicaid and add OhioRISE provider specialties between Aug. 1 and Sept. 30, 2022, to begin providing and billing for services. For guidance on this process, please view the OhioRISE Provider Enrollment During System Transition Guidance available on the Resources for Community Partners and Providers page of the OhioRISE webpage.

Effective October 1, 2022, all provider enrollment applications must be submitted using Ohio Medicaid’s new Provider Network Management (PNM) module. After its implementation, the PNM module will be the single point for providers to complete provider enrollment, centralized credentialing, and provider self-service.

Provider Network Management Portal and Centralized Credentialing

Beginning on October 1, 2022 the Provider Network Management (PNM) portal will accept Medicaid provider enrollments and carry out centralized credentialing functions. This transition will reduce administrative burden for providers and enable providers to focus on the more meaningful and important work of providing care to members.

Providers who are required to be credentialed will need to be credentialed only one time, rather than separate times for each managed care organization (MCO) with which it needs to be credentialed to contract.

As ODM prepares to transition to Centralized Credentialing on October 1, 2022 and streamline the process for claims and prior authorization submissions later in the year, we will send communications and provide trainings to inform and support providers, provider associations, and trading partners in understanding the changes they will experience. Training is expected to begin late summer 2022. In addition to trainings, ODM will communicate key dates and recommended actions to prepare providers, provider associations, and trading partners for the upcoming changes.

Additional details will be communicated through various channels including the PNM & Centralized Credentialing webpage and the ODM 2022 Press newsletter. To subscribe to the ODM 2022 Press, please fill out this form and be sure to check the “ODM 2022 Press” box.

Contracting with Ohio Medicaid Next Generation MCOs & Provider Credentialing

To learn more about how to contract with Ohio Medicaid’s Next Generation MCOs or how a provider becomes credentialed, refer to the Resources for Providers webpage.

Submitting Claims

Until ODM begins accepting claims through the Ohio Medicaid Enterprise System (OMES) modules – the PNM portal and Electronic Data Interchange (EDI) module for managed care claims and the Single Pharmacy Benefit Manager (SPBM) module for pharmacy claims – on December 1, 2022, provider claims will continue to be submitted according to the MCO billing guidance.

Once the OMES modules go live in stage 3 and there is “one front door” for claims, providers will benefit from streamlined processes and reduced administrative burden.

Prior Authorizations

Until ODM begins accepting prior authorization requests through the OMES PNM portal, EDI module, and SPBM module on December 1, 2022, prior authorizations will continue to be submitted following the prior authorization submission guidance outlined by the applicable MCO. Trading partners will need to work with providers and MCOs to verify prior authorizations continue to be submitted following the process outlined by the applicable MCO.

Once the OMES modules go live in stage 3 and there is “one front door” for prior authorizations, providers will benefit from streamlined processes and reduced administrative burden.

As a part of the next generation of Ohio’s Medicaid managed care program, the new PNM portal and Centralized Credentialing initiative will include customized user training available through a variety of channels to provide learning for all user types. Additional details about training is forthcoming.

Next Generation Ohio Medicaid Program Provider Overview Webinar 

The Ohio Department of Medicaid (ODM) hosted the Next Generation Ohio Medicaid Program Provider Overview Webinar in July to share information about exciting changes Ohio Medicaid providers can expect. The webinar included an overview of the transition to the Ohio Medicaid Enterprise System (OMES) modules - including Single Pharmacy Benefit Manager (SPBM), Provider Network Management (PNM), and the Fiscal Intermediary (FI)- and information about planned module-specific trainings.   

Please find a recording of the presentation and slides here: Providers | Ohio Medicaid Managed Care

Provider Network Management (PNM)

What is PNM?

ODM is in the process of modernizing its management information systems. This modernization roadmap, developed in accordance with the Centers for Medicare and Medicaid Services (CMS) guidance, includes a transition to a modular system called the Ohio Medicaid Enterprise System (OMES) that will support ODM in meeting several modernization goals.

As a part of this roadmap, updated and new functionality is being built into OMES rather than MITS. The PNM is a new modular component of OMES that will replace the current MITS provider enrollment subsystem and the current MITS provider portal.

What benefits are coming with PNM?

There are several new features and enhancements in the PNM that are designed to streamline processes and reduce administrative burdens for providers. 

  • Gives providers the ability to view specialties and effective dates.
  • Provider change or update requests submitted in the PNM can also be reviewed and accepted within the PNM. There is no need for email or letters. (Includes change of operator notices, name changes, adding specialties, etc.)
  • Provides a comprehensive provider directory at the state level.
  • Providers may opt in or out to text message notification options for providers.
  • No more paper agreements for long term care facilities – all agreements are available online and do not require mailing back and forth for signatures.

Centralized Credentialing

What is Centralized Credentialing and what benefits will it provide?

ODM is implementing a single, centralized provider credentialing process at the state level with the go-live of the PNM portal. There are many expected benefits of this centralized approach, including:

  • Providers subject to credentialing will only undergo one credentialing and recredentialing process at the state level vs. a separate additional process for each Ohio Medicaid managed care organization (MCO).
  • A Credentialing Verification Organization (CVO) – Maximus, Inc. – will maintain NCQA accreditation requirements for Ohio’s MCOs and serve as ODM’s single point of contact for providers as they undergo credentialing and recredentialing reviews.
  • By establishing delegate agreements with hospital systems and a delegate review process, ODM can deem credentialing work already completed by these providers and reduce or eliminate the need for individual providers such as physicians, nurse practitioners, etc. to engage in multiple credentialing processes. 

Centralized Credentialing Summary

For questions, please reach out to the following mailboxes: