1. Ohio Home Care Waiver Provider Application Process

2. medicaid.ohio.gov Provider Enrollment Website

3. Hover over the Providers Tab

4. Hover over Enrollment and Support

5. Click Provider Enrollment

6. On the next page, click “Enroll as a New Provider”

7. On this page, you will also find required application documents and a link to the MITS portal, located in the right margin as you scroll down the page.

8. After clicking ‘Enroll as a New Provider’, click ‘I need to enroll as a provider to bill Ohio Medicaid’ Even if you are a previous provider and wish to re- enroll, a new application is needed.

9. This will expand the Instructions box. Click ‘new application’ or ‘continue application’ in the lower right corner. ‘Continue application’ will resume an application in progress.

10. Application Page 2: Request Type

11. Select an enrollment type, either individual practitioner or organization. Please note that individuals should enroll as individual practitioners and not as organizations. Application Page 2, Continued

12. Choose the provider type for which you are applying. Application Page 2, Continued

13. If you are a re-enrolling provider, select ‘No’ for the question ‘Are you a provider new to Ohio Medicaid?’ and enter your 7- digit Medicaid number. If you are a new provider, select ‘Yes’. Application Page 2, Continued

14. Applicants will enter Identifying Information. Only fields marked with a * are required. Application Page 3: Identifying Information.

15. Application Fee for Agency Providers Agency providers will be prompted to pay an application fee. The fee is paid with the initial application and every 5 years at revalidation. Applicants will receive a confirmation number for the fee. This number must be entered in the Confirmation Number field at the bottom of the page. If the agency is a Medicare/Medicaid provider, and has paid the fee in the last 5years, answer ‘YES’ to the Medicare or Medicaid application fee question and submit proof of payment with the application.

16. Application Fee for Agency Providers, Continued

17. On page 4, an ATN is assigned and tax information is needed. The IRS effective date should be today’s date. The IRS end date auto-fills. Application Page 4: Tax Information

18. W-9 should be marked ‘YES’. Form 147 will be marked ‘NO’ for individuals. Organizations that need Form 147 will check ‘YES’. Application Page 4, Continued

19. This page requests DEA license information to administer drugs. Most applicants will not have a license to administer drugs and can click next. Application Page 5: DEA License

20. The Address Type needs to be practice location or the applicant will not be able to continue. Application Page 6: Address Information

21. This page will auto fill for individuals. The primary specialty box needs to be checked. Organizations may pick other specialties using the drop down options. Application Page 7: Type and Specialty

22. Provider Type & Specialties TYPESPECIALITYDESCRIPTION 16161Other accredited Home Health Agency 25250PCS - Personal Care Services 26260Home Care Attendant 38381RN 38383LPN 45/55450Home Meals 45/55451Supplemental Transport Services 45/55452Adult Day Health 45/55453Supplemental Adaptive/Assistive Devices 45/55455Home Delivered Meals 45/55454Minor Home Modifications 45/55456Out of Home Respite 45/55457Emergency Response System 60601Medicare Certified Home Health Agency

23. Applicants may add any additional languages they speak. Application Page 8: Language

24. Applicants affiliated with a group practice or practices would click add and fill in the information on this page. Most applicants will leave this page blank. Application Page 9: Group Affiliations

25. Disclose convictions here. Application Page 10: Criminal Offense I

26. Disclose convictions here. Application Page 11: Criminal Offense II

27. Disclose violations of State or Federal Law. Application Page 12: Violations of State or Federal Law

28. For re-enrolling providers, that previously had a Medicaid provider number, click yes and enter the previous provider ID. Application Page 13: Previously Participated

29. Any sanctions by the Medicare program must be entered. Application Page 14: Medicare Sanctions

30. To proceed all questions must be answered yes with the exception of the residency questions. Application Page 15: Addendum E

31. Application Page 15: Addendum E, Continued For LPNs, an RN supervisor’s name and license number is needed.

32. Application Page 15: Addendum E, Continued Relationship to consumer: Check ‘YES’ to indicate you meet the requirements to be the provider for the individual you will be providing services to. The provider cannot be the legally responsible family member. Legally responsible family members include Spouse Birth or adoptive parent (in the case of a minor) Foster caregiver

33. Check yes or no for each residency question. Applicants that have not been an Ohio resident for at least the last five years will need an FBI check in addition to a BCI background check to process the application. Application Page 15: Addendum E, Continued

34. The applicant must type an electronic signature at the bottom of the page.

35. Application Page 16: Certification Fill in Legal Entity Name and Individual Name. The primary practice address also needs to be completed. The Enrollment Checklist link provides a list of documents needed to complete the application.

36. All applicants must read and accept the terms. Use the scroll bar on the right of each section to read the terms and select ‘I accept the terms and conditions.’ Application Page 16: Certification, Continued

37. Check the provision check box and sign at the bottom.

38. Applicants will choose mail or upload for application documents and add any comments they feel are helpful. Click ‘submit’ at the bottom of the page to submit the application. Application Page 17: Documents Submission Type and Notes

39. A list of required documents will come up with address to send to. There are also links to upload documents and print the application. Application Page 18: Confirmation of Receipt

40. Note: the address on application is incorrect. Application Page 18: Confirmation of Receipt, Continued

41. Please Mail Documents To: Public Consulting Group Home and Community-Based Provider Oversight Services 155 East Broad Street, 8 th Floor Columbus, Ohio 43215 Fax: 1-614-386-1344 Email: OHProvidermaintenance@pcgus.com

42. Please Have Background Check Mailed to: Ohio Department of Medicaid Attn: BCI Coordinator PO Box 183017 Columbus, OH 43218

43. Uploading Documents after the Application Is Submitted

44. Go to the provider enrollment page and click “Check Provider Enrollment Status”

45. This will bring up a new page where applicants will enter the ATN assigned to the application and their last name. The last name must be in CAPS.

46. Applicants can check application and document status. At the bottom of the page, applicants can use the link to upload documents.

47. Click ‘Upload required documents’ to upload new documents. Select the document type to upload and browse to select the document being uploaded.