Ohio Dept Of Medicaid Providers


New Managed Care Provider Agreements

Ohio Department of Medicaid warns Austintown rehab about false claims

ODM analyzed the information gathered via two requests for information and listening sessions to develop a framework to create the next generation of Ohio Medicaids managed care program. The framework for the program includes:

  • Identification of first-generation program gaps: Feedback highlighted challenges with the current program many of which the state is constrained in addressing under the current Medicaid Provider Agreement.
  • Creation of a new contract: ODM developed a new Managed Care Organization Provider Agreement aimed at addressing current program constraints and member and provider suggestions.
  • Changes to the status quo: The new MCO Provider Agreement creates more opportunities to position ODM to better adapt and respond to the constantly changing health care needs of Ohioans.
  • Implementation of the procurement process: ODM released a request for applications to solicit responses from MCOs this will ultimately result in the issuance of the new MCO Provider Agreement to partners who will work with us to realize our mission.

Utilizing this framework, many new requirements have been added to the provider agreements. These new requirements can be found in the drop-downs below.

Video Result For Ohio Department Of Medicaid Providers

Medicaid Reimagined: Supporting Providers in Better…
ODM Managed Care Procurement Resources
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Medicaid Reimagined: Supporting Providers in Better…
ODM Managed Care Procurement Resources
EVV Provider Refresher Training – Visit Maintenance…
Direct Care Worker Training Video – SMC/TVV
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Become An Independent Provider

An independent provider is a self-employed person who directly provides services to people with developmental disabilities. They cannot employ someone else to provide services on their behalf.

Waiver certification applications for independent providers continue to be accepted by DODD through PSM at this time.

Independent providers must be at least 18 years old, have a valid Social Security number, and one of the following forms of identification:

  • State of Ohio identification,
  • valid driver license,
  • or other government-issued photo identification.

Independent providers must have a high school diploma or GED and be able to read, write, and understand English at a level sufficient to comply with all requirements set forth in administrative rules governing the services provided.

Independent providers must also hold a valid American Red Cross or equivalent certification in first aid and CPR, including an in-person skills assessment.

Independent providers are not employees of the State of Ohio or employees of the Ohio Department of Developmental Disabilities.

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Unitedhealthcare Senior Care Options Plan

UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.

Introducing Humana Healthy Horizons In Ohio

Mission of Ohio Medicaid Managed Care

Humana Healthy Horizons has served Medicaid populations continuously for more than 2 decades and currently manages Medicaid benefits for nearly 800,000 members nationally. We developed expertise providing care management, care planning, and specialized clinical management for the complex needs of members within a social supportsbased framework.

We also developed significant expertise in integrating physical health, behavioral health, pharmacy and social services and supports for a whole-person centered approach to improve the health and wellbeing of our members and the communities we serve.

In Ohio, Humana already serves 568,000 residents through Medicare Advantage, Medicare prescription drug plans, commercial employer-sponsored plans, commercial dental and vision coverage, and TRICARE.

For more than two decades, Humana has served Medicaid populations and currently manages Medicaid benefits for nearly 800,000 enrollees nationwide. Humana Healthy Horizons is committed to continue demonstrating our ability to manage complex populations and create solutions that lead to a better quality of life for our members.

We are pleased to announce that Humana Healthy Horizons in Ohio is launching in early 2022. In partnership with the Ohio Department of Medicaid, we will work with our provider network to serve our members in Ohio, and help them reach their health goals and get the right care in the right place at the right time.

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Member Advisory Council And Connected Advisors

UnitedHealthcare Care Managers for Member’s Unique Needs

Every UnitedHealthcare MyCare Ohio member receives a personal representative. These Care Managers are licensed professionals providing education and coordination of UnitedHealthcare Connected® for MyCare Ohio benefits, tailored for each member’s unique needs.

to watch a video on how these Care Managers are helping current members.

We recently mailed you a letter that included some information on benefit changes. Some of the information did not pertain to members that only have their Medicaid covered benefits through our plan. Please disregard that letter. The letter also had an incorrect number for the Ohio Medicaid Hotline. The correct number for the Hotline is 1-800-324-8680. We are sorry for any confusion this may have caused you. Please view the Member Clarification Letter for additional information.

Use the documents below to learn more about each important health topic.

  • PDF 180.50KB – Last Updated: 11/12/2020

UnitedHealthcare Member Advisory Council and “Connected Advisors”

UnitedHealthcare Member Advisory Council and “Connected Advisors” is an advisory council to ensure that UnitedHealthcare actively engages consumers, families, advocacy groups, and other key stakeholders as partners in the program design and delivery system.

Who is involved?

They will advise and guide the UnitedHealthcare Community Plan of Ohio on:

How is it organized?

What will they do?

  • PDF 26.62KB – Last Updated: 11/12/2020

Submit Application And Submission Fee

Pay the non-refundable fee, electronically sign, and submit the application.

All supporting documents must be submitted within 30 days of submitting the application and application fee.

The application is considered complete the date that all supporting documents have been submitted and the background check results are received by DODD. That becomes the application submission date.

After 30 days, applications missing documentation are closed and a new application and application fee will be required.

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Wellhop For Mom & Baby

Connect with other expectant moms. Get support and information during your pregnancy and after you deliver. This program is part of your health plan and there is no extra cost to you.

Heres how it works:

  • Join video conversations every other week with women who have similar due dates and a group leader.
  • Chat and share experiences with moms from your group on the Wellhop app or website.
  • Visit the Wellhop library. Youll find articles, videos and more.
  • PDF 4.58MB – Last Updated: 04/20/2021

Unitedhealthcare Dual Complete Plans

News 5 hidden-camera investigation sparks action by the Ohio Department of Medicaid

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call TTY 711 for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

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Local Presence And Communication

MCOs must respond to requests for information within the following timeframes:

  • Within 24 hours for requests regarding member health, safety, and welfare.
  • Within two business days for requests regarding member access to services.
  • Within five business days for requests received through HealthTrack, for member inquiries.
  • Within five business days for constituent inquiries received through external business relations.
  • Ten business days for requests regarding policy research queries, coding, rate change inquiries, and all other requests for information.

Medicaid Managed Care Annual Open Enrollment

Beginning September 17, 2021, Ohio Medicaid managed care members will be able to select their plan by calling the Ohio Medicaid Consumer Hotline at 1-800-324-8680 or utilizing the Ohio Medicaid Consumer Hotline Member Portal. You do not have to do anything if you want to keep your current Medicaid Managed Care Plan.

Visit the Ohio Medicaid Consumer Hotline website for information.

Questions about CareSource?

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New Services Are Being Added To Ohio Home Care Waiver

Effective July 1, 2019, three new home and community-based services will be available to individuals enrolled on the Ohio Home Care Waiver. The new services are Community Integration, Community Transition and Home Maintenance/Chore. To find out more about the services and determine if or how you can become a provider. .

Medicaid State Plan Services


Administered by the Ohio Department of Medicaid, Ohios Medicaid State Plan services cover a wide range of needs, including doctor visits, prescriptions, medical equipment at home, dental and vision services, pregnancy care, and mental health services.

Visit the Medicaid.Ohio.gov for more information about the kinds of services, who can get services, or how to apply for Medicaid State Plan services.

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Program Announcements And Updates


  • Final Program Year 2021 now open. A new resource page for the final program year is now available through the provider portal visit the Medicaid Promoting Interoperability Program Sunset Informational Page for additional information on Program Year 2021.
  • Attestation for Program Year 2020 is now closed.
MPIP portal open to accept Final Program Year 2021 attestations on April 1, 2021
Portal Close Date MPIP portal Program Year 2021 deadline is
EHR Reporting Period Any continuous 90-day period between January 1, 2021 and August 30, 2021
Certified EHR Technology
Any continuous 90-day period between January 1,2021 and August 30, 2021
Total eCQMs Required for Reporting 6
Total number of CQMs Available 53

Program Year 2020: What’s new for EPs?

MPIP portal open to accept Program Year 2020 attestations on April 1, 2020
Portal Close Date MPIP portal Program Year 2020 deadline is
EHR Reporting Period Any continuous 90-day period between January 1, 2020 and December 31, 2020
Certified EHR Technology
Any continuous 90-day period within calendar year 2020
Total eCQMs Required for Reporting 6
Total number of CQMs Available 53

Program Year 2019: What’s new for EPs?

For more information regarding the online MPIP attestation process, updated Program Year resource documents and answers to additional questions, please visit the MPIP Resources page.

Ready to attest?

Start With Background Check

An application packet will not be ready for review until all supporting documents, including background checks, are submitted.

Background checks are submitted directly to DODD from the Ohio Attorney Generals Office.

To start the background check, visit a WebCheck location.

The results of a background check can take up to 45 days to be completed and sent to DODD.

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We Know Youre Going To Have Questions

Ohio Medicaids new approach to managed care is based on extensive feedback we received from providers, Ohio Medicaid members, and other key stakeholders about the way the current system was working for them. We know that you face an increasingly complex set of requirements that can take valuable time and energy away from what you entered medicine to do: help people stay well.

While our new approach is designed to reduce administrative burden and make it easier to deliver a more personalized type of care, we know youll still have questions. Ohio Medicaid has established dedicated support to answer your questions. Visit the managedcare.medicaid.ohio.gov website for the latest information regarding Ohios next generation managed care program and initiatives, and feel free to send us a message at .

Contracting With The Spbm Vendor Gainwell Technologies

Medicaid Reimagined: Supporting Providers in Better Patient Care

Pharmacies must be enrolled with ODM to contract with the SPBM vendor, Gainwell Technologies. Pharmacies can enroll at any time if they are not already enrolled.

The pharmacy will then need to contract with Gainwell. All pharmacies will have to contract with Gainwell to provide pharmacy services for Medicaid managed care members. For pharmacy contracting questions, Gainwell may be reached by email at or by phone at 491-0364.

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Providers Subject To On

Federal and state laws require some providers to have pre- and post-enrollment on-site screening visits to ensure program integrity. .

In Ohio, the Public Consulting Group, Inc. will conduct these visits for providers that are not already screened by another state or federal agency. On-site screening visits are conducted without prior notification or appointment. The PCG representatives will have a business card and a letter of introduction, for your verification.

When the PCG representatives arrive at your office, please take a few moments to answer their questions and allow them access to your facility. This will help to complete your on-site visit smoothly. During your site visit, the PCG representatives will review various aspects of your business. Failure to answer their questions and cooperate with the PCG representatives could affect your enrollment or current provider status with Ohio Medicaid.

Ohio Medicaid And Managed Care Organizations

Today, more than 90 percent of Ohio Medicaid members are supported by managed care organizations . During the year ahead, ODM will begin implementing a new vision for care focusing on the individual, a strong partnership among MCOs and the department, and supporting specialization in addressing critical needs.

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Contracting With Odms Next Generation Mcos

Providers interested in contracting with Ohio Medicaids next generation MCOs can contact them via the Provider Relations contact information listed in the table below.

Next Generation MCO Provider Relations Contact Information

Anthem Blue Cross and Blue Shield*


Humana Healthy Horizons in Ohio


Molina Healthcare of Ohio, Inc.


UnitedHealthcare Community Plan of Ohio, Inc.


*Administered by Paramount Advantage in West and Northeast Region until implementation of the Next Generation MCOs before the year ends.

Once live in October 2022, Centralized Credentialing will simplify the credentialing process for Medicaid providers providers will no longer seek credentialing through each MCO.

Ohio Medicaid Provider Exclusion And Suspension List


The Ohio Department of Medicaid was founded in July 2013. It is the premier Executive-level Medicaid agency of the state of Ohio. Led by Director John B. McCarthy and in partnership with the Governors Office of Health Transformation, the ODM provides health care coverage to 2.9 million residents daily, through 83,000 providers.

Through the Ohio Revised Code, the Ohio Department of Medicaid has been granted rule-making authority which covers:

1.) Adoption of new rules.

2.) Amendment/Repealing of current rules.

These rules are accessible here: Medicaid Program Rules, Section 5160

One of ODMs core commitments is to provide Ohios families and taxpayers with healthcare service of utmost efficiency and transparency through, among other things, a relentless fight against healthcare fraud.

Although the Ohio Department of Medicaid regularly updates its own list of suspended individuals/entities, which is accessible via this link: Ohio Medicaid Provider Exclusion Suspension List , it nonetheless urges providers to conduct database searches using these sources:

Some stats from the LEIE regarding Ohio.

To learn more about LEIE stats see our infographic

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Unitedhealthcare Connected Benefit Disclaimer

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

You can get this document for free in other formats, such as large print, braille, or audio. Call , TTY 711, 8 a.m. – 8 p.m., local time, Monday – Friday . The call is free.

You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future.

Language Line is available for all in-network providers.

Puede obtener este documento de forma gratuita en otros formatos, como letra de imprenta grande, braille o audio. Llame al , TTY 711, de 08:00 a. m. a 08:00 p. m., hora local, de lunes a viernes correo de voz disponible las 24 horas del día,/los 7 días de la semana). La llamada es gratuita.

Puede llamar a Servicios para Miembros y pedirnos que registremos en nuestro sistema que le gustaría recibir documentos en español, en letra de imprenta grande, braille o audio, ahora y en el futuro.

Los servicios Language Line están disponibles para todos los proveedores dentro de la red.

Medicaid Managed Care Plans

People accessing services through a Home and Community-based Services Waiver, like DODD’s Level One, Individual Options, or Self-Empowered Life Funding waivers, can enroll in a Medicaid managed care plan, which offers benefits like

  • one permanent card, rather than a new paper card each month,
  • more health care providers in your network and help finding health care providers,
  • a dedicated toll-free number for questions and 24-hour nurse advice line,
  • health and wellness programs,

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Mental Health And Substance Abuse Services

Get help with personal problems that may affect your mental or physical health. These may include stress, depression, anxiety or drugs and alcohol abuse. Our services also include:

  • Therapy
  • Counseling
  • Medications

For some of these services prior approval is required. Please contact Member Services to learn more.

With our plan there are no copayments for covered services.

Members get:

  • Care from highly skilled and compassionate doctors.
  • Treatments at respected hospitals and clinics.
  • Home medical equipment and supplies to help them be their best.


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