Ohio Medicaid: Enroll in the Provider Network Management system today

The Ohio Department of Medicaid (ODM) now requires all providers who deliver services to Medicaid managed care members to be enrolled in the Provider Network Management (PNM) system. If you’re not enrolled and active, your claims may be rejected or denied.

What you need to do

1. Verify enrollment status in PNM
2. Complete enrollment immediately if not active
3. Ensure proper affiliations are established on the date of service
4. Submit claims only after enrollment is confirmed

What’s changed

• Providers must be enrolled and active in ODM’s PNM system before rendering and billing for Medicaid services
• Managed care entities (MCEs) cannot pay claims for providers who are not enrolled
• Claims submitted by unenrolled providers will be:
  • Rejected at the Electronic Data Interchange (EDI) front door
  • Not paid
  • Not accepted as encounters 

What happens if you don’t enroll

If you’re not enrolled before claim payment and encounter submissions:

• Claims may be held until enrollment is complete
• Encounters may reject if billing and rendering providers are not affiliated in PNM, or if the affiliation is missing or invalid in ODM’s system
• MCEs may deny claims if:
  • The provider refuses enrollment after outreach
  • At least 180 days have passed since initial notification
  • Documentation shows education and outreach efforts were made 
  • Denials should include CARC 226 and RARC N767
• Payment cannot be recouped if already made due to enrollment issues

Who must enroll in the PNM system

These requirements apply to all providers who:

• Serve Medicaid managed care members
• Serve OhioRISE members
• Bill services through the Single Pharmacy Benefit Manager (SPBM)

Please note: Providers enrolled in Medicare must also enroll in Ohio Medicaid to receive payment for dual-eligible members.

Enrollment options

If you’re not enrolled, you can enroll one of the following ways:

1. Online PNM enrollment (preferred)

• Submit an application through the PNM portal using the MCP Single Case option
• Results in a standard 5-year provider agreement 

2. Paper enrollment

• Complete the forms:
  • ODM 10282
  • ODM 10283
• Submit to the MCE, which will forward to ODM
• Results in a 5-year provider agreement

3. Temporary enrollment

    This option is only allowed once; providers must complete full enrollment after expiration.

• Complete ODM form 10295
• Submit through the MCE
• Results in a 120-day temporary enrollment

4. Pharmacy enrollment

• Pharmacies should use ODM form 10298 (facilitated by SPBM/Gainwell) 

Single case agreement providers

If you’re a single case agreement (SCA) provider, you’re enrolled as Provider Type 19 (PT19). This means you have limited affiliation capabilities but may retroactively enroll up to 365 days (with restrictions).

Resources

Visit the ODM Provider Education & Training Resources.