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
Choose the provider type for which you are applying. Application Page 2, Continued
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
Applicants will enter Identifying Information. Only fields marked with a * are required. Application Page 3: Identifying Information.
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.
Application Fee for Agency Providers, Continued
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
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
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
The Address Type needs to be practice location or the applicant will not be able to continue. Application Page 6: Address Information
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
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
Applicants may add any additional languages they speak. Application Page 8: Language
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
Disclose convictions here. Application Page 10: Criminal Offense I
Disclose convictions here. Application Page 11: Criminal Offense II
Disclose violations of State or Federal Law. Application Page 12: Violations of State or Federal Law
For re-enrolling providers, that previously had a Medicaid provider number, click yes and enter the previous provider ID. Application Page 13: Previously Participated
Any sanctions by the Medicare program must be entered. Application Page 14: Medicare Sanctions
To proceed all questions must be answered yes with the exception of the residency questions. Application Page 15: Addendum E
Application Page 15: Addendum E, Continued For LPNs, an RN supervisor’s name and license number is needed.
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
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
The applicant must type an electronic signature at the bottom of the page.
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.
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
Check the provision check box and sign at the bottom.
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
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
Note: the address on application is incorrect. Application Page 18: Confirmation of Receipt, Continued
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
Please Have Background Check Mailed to: Ohio Department of Medicaid Attn: BCI Coordinator PO Box 183017 Columbus, OH 43218
Uploading Documents after the Application Is Submitted
Go to the provider enrollment page and click “Check Provider Enrollment Status”
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.
Applicants can check application and document status. At the bottom of the page, applicants can use the link to upload documents.
Click ‘Upload required documents’ to upload new documents. Select the document type to upload and browse to select the document being uploaded.