This step-by step guide will help you apply for certification as an Agency, Non- Agency or Assisted Living provider. PLEASE NOTE: You must serve two consumers for a three month period prior to applying for certification. If you have not served two consumers for a three month period, you are not eligible to apply until this condition is met. You begin the process by applying through Ohio Department of Jobs and Family Services (ODJS) website using the Medicaid Information Technology System (MITS). Click on this link https://portal.ohmits.com/public/providers/tabid/43/default.aspx. Select Provider Enrollment Application from the options listed on the right side of the screen.
PLEASE NOTE: the checklist and FAQ provided on this screen is for applicants applying to an ODJFS waiver program. It will not provide you with a checklist or FAQ to apply to the Ohio Department of Aging (ODA). Select New Application.
Enrollment Type: Select Organization. Action Request: will always be Initial Enrollment. Provider Type: 45 Waivered Services Organization OR 74 Home and Community Based ODA Assisted Living Click Next to continue.
Enter all required fields where an asterisk (*) is located. Organization Legal Name: type the legal name of your business. Ownership Type: Select from the drop down box the option the best represents your business. Type: Select FEIN from the drop down box. SSN/FEIN: Type your Federal Tax ID number. OPTIONAL: If you are doing business as (DBA), please type your DBA in the field provided. No other information is required. Please leave all other fields blank. Click Next to continue.
IRS Tax Type: Select FEIN. IRS Tax ID: Type your Federal Tax ID number in the space. PLEASE NOTE: The system may not require you to answer the remaining fields. This would happen if you are reentering a second application or if you are currently a Medicaid Waiver Provider through another waiver program (e.g., ODJFS, DODD, etc). Complete your name, address, city and zip. Select date you are completing the MITS application as the IRS Effective Date. W-9 Form: Select Yes. All other fields remain blank. Click Next to continue.
Address Type: Practice Location is the default option. This is the address where you conduct your business. Enter all required fields where an asterisk (*) is located. Address Type Options: Please complete the required information for the following options by selecting Add. Home/Corporate Office Mail To/Correspondence Pay To Alt Practice Location Click Next to continue.
Specialty: Select 480-ODA Waiver from the drop down box for PASSPORT Waiver. Select 740-Home and Community Based Assisted Living for the Assisted Living Waiver. Primary Specialty: Click the box All other fields remain blank. Click Next to continue.
You are not required to complete this screen. Click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Type of Entity or Practice: Select the type of business (example: sole proprietor, corporation, etc). If other, specify the type of business in the field provided (example: LLC, etc). Click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
If your agency currently has a Medicaid Provider Number and are providing services through another state agency (ODJFS, DODD, etc.), please select Yes and provide your Medicaid Provider Number in the field. If you have more than one Medicaid Provider Number, select add and complete the step listed above. If no, click Next to continue.
If your agency is a corporation or LLC, select Yes and completed the required fields. If you have more than one owner/director, select Add and repeat the process. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Read the question and select the appropriate answer (yes or no). If yes, please complete the fields as requested the click Next to continue. If no, click Next to continue.
Enter all required fields where an asterisk (*) is located. EMAIL ADDRESS: THIS FIELD MUST BE COMPLETED. Read the statement and scroll down prior to selecting I accept the terms and conditions. PLEASE NOTE: You must accept all the terms and conditions on this page before you can complete the application. If you do not agree to the terms and conditions, you will not be eligible to be certified as a Medicaid Waiver Provider. Click Next to continue.
Document Submission Type: Select Mail from the drop down box. No additional information is required. The space can be left blank. Click Submit to finalize you application in the MITS system.
These documents will be emailed to you by ODA. You have successfully completed your application in the MITS program. Your tracking number is displayed above. Be sure to write the ATN number down. You will be asked for the ATN number if you call to check the status of your application. Signed Agreement & W-9 Form: ODA will email a copy of these documents when you are notified through email by our office. Both documents will need to be completed and signed. These documents will be included when you return the required ODA application material. ODA will upload all required documentation in MITS. You may print a copy of the application for your records by selecting Print Application. Click Exit to end the application process.
What to Expect: Within 10-15 business days, an email will be sent from ODA to the email address you provided on the application. Included in the email will be: Checklist indicating the additional documentation that is need for certification. Ohio Department of Aging Application for Certification as an Agency, Non-Agency or Assisted Living Provider. Instruction for applicants seeking certification. A copy of the MITS Application. Blank W-9 form. All documentation must be completed and returned to ODA within thirty (30) business days. If you have any questions, please feel free to contact our office at 614-644-1737. Thank you for your interest in becoming a certified provider with the Ohio Department of Aging.