Ohio Department of Medicaid (ODM) has and continues to prepare providers for the launch of the Next Generation program through provider awareness and training efforts. Recordings of past trainings are available below, and several resources including one-pagers and FAQs are linked in the “For more information” box to the right.
1. Next Generation February 1 Launch Provider Webinar
On January 19, 2023, the Ohio Department of Medicaid conducted a webinar for providers to learn about exciting changes with the February 1 launch. This webinar included information about the changes Ohio Medicaid providers could expect, including an overview of the transition to the Next Generation managed care plans, Electronic Data Interchange, and Fiscal Intermediary.
If you were unable to attend, below you can find the presentation and recording.
For questions, please contact ODMNextGen@medicaid.ohio.gov.
2. Provider Network Management (PNM) Refresher Training
Ohio Department of Medicaid (ODM) aims to prepare providers for the subsequent launches of the Next Generation program through provider awareness and training efforts. Additional details about the subsequent changes will be communicated through various channels including the PNM & Centralized Credentialing webpage and the ODM Press newsletter. To subscribe to the ODM Press, please fill out this form and be sure to check the “ODM Press” box.
Training module topics will include the following:
- Self-service hospice.
- Fee-for-service and managed care claims submission (dental, institutional, and professional).
- Fee-for-service and managed care prior authorization submission.
- Fee-for-service and managed care eligibility inquiry.
- Fee-for-service and managed care claims inquiry.
- Fee-for-service and managed care provider financials/remittance advice.
- Cost report submission process via Ohio Medicaid Enterprise System (OMES) cost report and rate setting web portal for long term care (LTC), hospital, Medicaid school base, federal qualified health center (FQHC), rural health center (RHC), and outpatient health facility (OHF) providers.
To learn more about the PNM module and Centralized Credentialing, visit the PNM and Centralized Credentialing page. If you are experiencing any technical issues accessing the PNM module or have specific questions, please contact Medicaid’s Integrated Help Desk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. The IHD is open Monday-Friday, 8 a.m.-4:30 p.m. Eastern time.
3. Provider Journey Maps
What is a Provider Journey Map?
Provider journey maps are process maps that visually illustrate various activities required for providers to perform as part of their participation with the Next Generation program. The maps detail common provider activities, explaining the main actions providers perform since October 1. We encourage providers to review these maps to understand, from a high-level, how common activities will be performed and how they can prepare for these activities. Please see below for the comprehensive list of provider journey maps.
October 1 – Provider Journey Maps
February 1 – Provider Journey Maps
4. October 1 Provider Network Management (PNM) Training
PNM Training and Learning Management System
In partnership with Ohio Department of Medicaid, Maximus – the PNM module vendor – offered a variety of trainings to prepare providers for the October 1 launch of the PNM module and centralized credentialing. Providers can access the self-paced training and recordings of past sessions by visiting Absorb, the learning management system (LMS), is where providers can access the self-paced training and recordings of past sessions.
It is important that you create an account in the LMS to ensure you have access to all training sessions, answer forms, and PNM resources. Visit the Job Aid for instructions on how to access the LMS and follow the steps to create your account and access PNM training.
5. Single Pharmacy Benefit Manager (SPBM) Portal Training
Helpful information, resources, and links to recordings of Gainwell Technology’s SPBM training sessions can be found by navigating to https://spbm.medicaid.ohio.gov and selecting the “Provider” tab. Under this, you will find the menu for “SPBM Web Portal Training.”
The public-facing SPBM web portal provides instant access to reference material such as the Unified Preferred Drug List (UPDL) and criteria, the Preferred Diabetic Supply list, the Specialty Drug list, and Quantity Limits list to assist with prescribing medications to Ohio Medicaid managed care members.
The secure SPBM web portal requires credentials and provides a way to check eligibility of Ohio Medicaid managed care members, the ability for prescribers to submit prior authorizations, the ability to view claim and prior authorization history, and a secure web chat to quickly speak with the SPBM help desk.
If you have any questions regarding SPBM web portal training, please email OH_MCD_PBM@gainwelltechnologies.com.
6. Ohio Medicaid Single Pharmacy Benefit Manager (SPBM) Webinar Recordings
March 11: SPBM Pharmacy Pricing and Audit Consultant (PPAC) Webinar
- Prepaid Ambulatory Health Plan (PAHP) overview.
- Contract overview.
April 15: SPBM Specialty Pharmacy Webinar
- Network criteria/credentialing.
- Specialty drug list methodology.
- Ingredient cost methodology/Ohio Average Acquisition Cost (OAAC) survey/expected pricing structure.
- Dispensing fee structure.
- Submission of claims – medical vs. Rx benefit.
- 340B considerations.
- Prior authorization process.
- Prescribing considerations/member journey.
- OAAC survey process.
June 17: SPBM Pharmacy Reimbursement Webinar
- Overview of Next Generation Pharmacy Program reimbursement structure.
- Dispensing fee overview and philosophy.
- SPBM tier scoring methodology.
- SPBM dispensing fee tiers/rates.
- Dispensing fee operational considerations.
- Ohio Average Acquisition Cost (OAAC) review.
- OAAC rates.
- OAAC operational considerations.
- SPBM contracting timelines and next steps.
7. Pharmacists: Updated Provider Manual
What is the SPBM Provider Manual?
As of October 1, pharmacy benefits for Medicaid managed care members covered by the Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies. Gainwell’s provider manual, also known as the pharmacy reference guide, is the primary resource guide providing key information to pharmacy providers, pharmacy support staff, and prescribers. 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.