[Ohio] Requirements to Enroll Providers in PNM

REQUIREMENTS: By June 3, 2026: Billing team must implement the following: 1. IDENTIFY UNENROLLED PROVIDERS: Audit all rendering providers currently billing for Ohio Medicaid Managed Care, Next Generation MyCare Ohio, OhioRISE, and SPBM beneficiaries. Flag any providers not enrolled with ODM (especially out-of-state providers and emergency service providers). 2. NOTIFY PROVIDERS: Contact all unenrolled providers in writing and inform them of mandatory enrollment requirements. Provide all three enrollment options: - Option 1: Online PNM enrollment via "MCP Single Case" tile at the PNM portal (5-year agreement) - Option 2: Complete ODM forms 10282 and 10283, submit to CareSource for transmission to Medicaid_Provider_Update@medicaid.ohio.gov with subject line "Single Case Agreement" (5-year agreement) - Option 3: Complete simplified ODM form 10295, submit to CareSource for transmission to ODM (120-day limited agreement only) 3. DOCUMENT PROVIDER EDUCATION: Maintain records of provider notification and education efforts; this documentation is required before CareSource will deny claims from providers who refuse to enroll. 4. UPDATE BILLING SYSTEM: Configure EDI claims submission to automatically reject and flag claims from unenrolled providers. Implement workflow to hold claims pending enrollment completion (note: this does not violate prompt-pay requirements as claims are not "clean claims" until provider is enrolled). 5. VERIFY AFFILIATIONS: Ensure billing and rendering provider affiliations are established in ODM's PNM system BEFORE date of service for claims to be paid. For MyCare Ohio encounters, verify that rendering providers have valid affiliations; encounters will reject if affiliation is missing or invalid. 6. PHARMACY SPECIAL HANDLING: Only Gainwell Network staff should use ODM form 10298 for pharmacy single case agreements under SPBM; inform pharmacy providers to use appropriate enrollment option. 7. ALERT PROVIDERS: Communicate that: - Claims from unenrolled providers WILL BE DENIED and not paid - Plan encounters from unenrolled providers WILL NOT BE ACCEPTED - Providers with 120-day agreements (form 10295) can only have ONE 120-day period; after expiration, must apply for full enrollment - PT19 (reporting only provider) enrollments can only affiliate to PT21 (Professional Medical Group) - Providers and affiliations must be active on date of service for original claims to be paid CONSEQUENCES OF INACTION: All claims from unenrolled providers will be rejected at the EDI front door and not paid; encounters from unenrolled providers will not be accepted by the MCE.