Next Generation Program
On February 1, 2023, Ohio Medicaid implemented the Next Generation managed care plans. These changes provide Ohio Medicaid managed care members enhanced healthcare services that best fit their individual healthcare needs and streamline claims and prior authorizations for providers.For information on OhioRISE, please see the updated OhioRISE Provider Enrollment and Billing Guidance.
Also launched on February 1, 2023, as part of the Next Generation program are the Electronic Data Interchange (EDI) and the Fiscal Intermediary (FI). The EDI is the new exchange point for trading partners on all claims-related activities, providing transparency and visibility regarding care and services. The FI facilitates the processing of claims via the EDI. Providers, trading partners, and managed care entities will not directly interact with the FI. Providers who direct data entry (DDE) managed care claims and prior authorizations do so through each managed care entity’s portals or their respective electronic processes.
Additional information and links to resources about these can be found in our February 1, 2023 Launch Ohio MedicaidProvider One-Pager,and February 1, 2023 Launch Ohio MedicaidProvider HelpdeskOne-Pager.
About the PNM module
Ohio Department of Medicaid (ODM) is excited to announce that the Provider Network Management (PNM) module went live on October 1, 2022! The PNM module serves as the single-entry point for secure portal functions such as claims submissions, prior authorizations, and member eligibility verification. Since October 1, 2022, providers are redirected from the PNM module to the appropriate MITS functionality.
What actions do I need to take?
- An OH|ID is required for providers to access the PNM module. If you do not have an existing OH|ID, you will need to create one to access the PNM module.
- Access the PNM module by clicking here.
- Click on the “Don't Have an Account Click Here” link on the PNM homepage. You will be redirected to the OH|ID site to create your new account.
- If you need assistance or experience technical issues, contact the ODM Integrated Help Desk at 800-686-1516 orIHD@medicaid.ohio.gov.
- If you have an OH|ID or once you have created one, use your new OH|ID to log in to the PNM module by clicking here.
- Setup your Administrator & Agent roles in the PNM module. Remember, these will need to be reestablished in the PNM module. For more information, access the .
You are now able to access the features and functionality available in the PNM module.If you need technical assistance or encounter an error accessing the PNM, please contact the ODM Integrated Help Desk Command Center at 800-686-1516. If you have questions about OH|ID, please visit the OH|ID Help Center.
Getting help with module issues and questions
If you are having trouble with the PNM module, here are some helpful resources that you can use to resolve the most common issuesproviders are experiencing:
- Identifying your role within PNM – Click this link for information on how to determine what role you are currently assigned to in the PNM module.
- – Click this link for information on how an Administrator can assign agent roles.
- Finding Your OH|ID - Click this link for information on how to locate your OH|ID user ID number.
- Enabling SMS Recovery for OH|ID – Click this link for information on how to enable SMS recovery for your OH|ID username or password.
- Assigning Medicaid IDs to administer PNM module accounts – Call the Ohio Medicaid Integrated Help Desk at 1-800-686-1516 and select option 2, and then select option 3 to speak to a live agent. Call representatives will confirm provider credentials prior to updating the system. A call-back option is available. Additional information about this change can be found further down on this webpage.
- PNM Affiliations QRG– Click this link for step-by-step instructions and information on affiliations within the PNM module.
Important update: Terminations to resume effective January 23, 2024, for failure to complete Medicaid Agreement Revalidations in the Provider Network Management module
If you are currently due for a revalidation in the Provider Network Management (PNM) module, it is imperative that you take immediate action to complete and submit your revalidation application to renew your Ohio Medicaid Provider Agreement. Ohio Department of Medicaid (ODM) will begin terminating providers who fail to complete their revalidation prior to their specified deadline, starting January 23, 2024.
ODM resumed provider revalidation notices in June 2023 as part of the federally required unwinding process from the COVID public health emergency. ODM issues a series of notices with the first one delivered 120 days prior to your Medicaid agreement end date. Subsequent reminders are issued at 90 days, 60 days, and a final notice at 30 days. If you receive a revalidation notice, it is imperative that you take action to complete your revalidation on time. All providers are subject to either three- or five-year time-limited provider agreements.
How do you know if you are due for revalidation?
1. Check your mail and email.
Revalidation reminder notices are mailed and emailed to providers who are due for revalidation prior to the end of their Medicaid agreement. The email will be sent from OHPNM@maximus.com to advise you of a revalidation notice in the PNM Correspondence folder. Please check your spam folder for this email.
2. View the Correspondence folder in the PNM module.
Revalidation notices are posted in the PNM module and can be accessed in the Correspondence folder. Please be sure to select the type of correspondence from the drop down (in this case <Enrollment Notices>), and search for the “Revalidation Notices.” Review the Accessing Communications within PNM Quick Reference Guide for step-by-step instructions.
NOTE: If you think you are due for revalidation but have not received notices, please login to the PNM module and verify that the primary contact information is accurate in accordance with your Ohio Medicaid Provider Agreement. All mailers and email notices are directed to the primary contact individual or address identified in the system.
If I am due for revalidation, what action do I need to take?
A “Begin Revalidation” option appears in the PNM Enrollment Action Selections 120 days prior to the Medicaid Agreement end date. This can be found under the “Manage Application”, “Enrollment Actions” option within the provider file. Review the Revalidation/Reenrollment Quick Reference Guide for step-by-step instructions.
New form required when requesting an Administrator change within the Provider Network Management module
Ohio Department of Medicaid (ODM) developed a new form, ODM10304, that must accompany requests to change Provider Network Management (PNM) Administrators from one billing organization provider to another. As a security measure, you must submit a formal request to transfer Administrator ownership of a Medicaid ID within the PNM module.
When should you use this form?
This form should be used when a practitioner leaves one provider organization and is employed with a new provider organization; and they are requesting that a new PNM Administrator be assigned to manage that individual practitioner’s Ohio Medicaid provider account. The Administrator role is key within the PNM module, as it permits ongoing management of organization and practitioner records. ODM understands that, in most cases, individual practitioners do not manage their own provider data within the PNM module. This form accounts for that and requires acknowledgment and authorization from the individual practitioner.
When is it not necessary to use this form?
You don’t need to submit this form if the PNM Administrator role is going to be transferred from one employee to another within the same provider organization. The PNM Administrator role can be transferred within a provider organization as a self-service feature available to the PNM Administrator. The current PNM Administrator can simply login to the PNM and reassign the role to another individual at that provider organization. Review the Changing Provider Administrators Quick Reference Guide for step-by-step instructions on completing this task. Additionally, Ohio Department of Developmental Disabilities (DODD) and Ohio Department of Aging (ODA) providers are not required to utilize the ODM10304 form and should follow the instructions provided by the respective partner agencies.
What action do I need to take if changing a PNM Administrator across organizations?
Access the ODM10304 PNM System Administrator Change Request and complete all required fields.
Email the completed and signed ODM10304 PNM System Administrator Change Request to PNMSupport@medicaid.ohio.gov with the subject line “Administrator Change Request.”
Update addresses and affiliations in the Provider Network Management (PNM) module
It is imperative that providers update all address and affiliation information in the PNM so that claims payments, provider directories, and network adequacy measurements are not negatively impacted.
Click on the following links for step-by-step instructions on how to complete these actions.
- Updating or Adding Owner Information
- Updating or Adding Practice Locations
- Updating or Adding a Specialty in PNM
PNM affiliation steps are not complete and may impact provider billing
Through a series of PNM queries, Ohio Department of Medicaid (ODM) has identified several affiliation issues that impact billing organizations claims. It is imperative that providers fully execute all steps when affiliating a rendering provider to their group/organization/hospital to avoid claims payment issues. ODM has identified that providers tend to leave affiliations in one of two incomplete statuses (Affiliation Status):
- Pending Approval
- Confirmed
A provider affiliation can be initiated and completed by the group/organization/hospital, or it can be initiated through the rendering practitioner. If the affiliation is initiated through the rendering individual, it is not complete and remains in a “Pending Approval” status until the group/organization/hospital accepts and saves the affiliation. At that point it will appear as “Confirmed”. For the provider affiliation to be sent downstream and receive an “Active” status, there are two remaining critical steps:
Click <Save> at the top of the page, which saves all the updates. Once saved, the user will have a new <Submit for Review> button appear.
Click <Submit for Review>. Users must click on this button to complete the process and submit the affiliations downstream. Affiliations are fully executed ONLY once this final step has been taken.
Important: If these steps are not completed, the provider affiliation is not sent downstream, and providers will experience claims payment issues.
