Ohio - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Ohio Department of Medicaid (ODM) covers skilled nursing services delivered in the home under two primary authorities: standard Home Health Nursing governed by Ohio Administrative Code (OAC) 5160-12-01, and Waiver Nursing delivered through programs like the Ohio Home Care Waiver. These services require a physician's order and a documented face-to-face encounter within 90 days prior to or 30 days following the start of care.

Approval to bill for these services requires an agency to first obtain a Home Health Agency license from the Ohio Department of Health (ODH), followed by either Medicare certification or national accreditation from an approved body such as CHAP, ACHC, or the Joint Commission. Only after securing this federal certification or national accreditation can an agency submit a Medicaid provider enrollment application through Ohio's Provider Network Management (PNM) module.

1. Service Definition and Scope

In Ohio, Home Health Nursing includes services provided by registered nurses (RNs) and licensed practical nurses (LPNs) under the direction of an RN. These services are delivered in the individual's home to treat a specific illness, injury, or condition.

The state differentiates between intermittent home health nursing under the Medicaid state plan and continuous Waiver Nursing or Private Duty Nursing (PDN) authorized under specific Home and Community-Based Services (HCBS) waivers.

• Service Types: Intermittent Home Health Nursing, Waiver Nursing, and Private Duty Nursing (PDN).
• Authorizing Document: Requires a physician's order and a face-to-face encounter documented within 90 days prior or 30 days after the start of care.
• Plan of Care: Must be documented on the ODM-approved person-centered services plan for waiver enrollees.
• Eligible Providers: RNs and LPNs employed by a Medicare Certified Home Health Agency (MCHHA) or an otherwise-accredited agency.

2. Regulatory and Oversight Agencies

The Ohio Department of Health (ODH) is the regulatory body responsible for licensing Home Health Agencies in the state. The Ohio Department of Medicaid (ODM) oversees provider enrollment and Medicaid billing.

For waiver-specific services, oversight is shared with the Ohio Department of Aging (ODA) and the Ohio Department of Developmental Disabilities (DODD), depending on the specific waiver program.

• Ohio Department of Health (ODH): Licenses Home Health Agencies and conducts readiness surveys https://odh.ohio.gov
• Ohio Department of Medicaid (ODM): Administers the Medicaid state plan and Ohio Home Care Waiver https://medicaid.ohio.gov
• Provider Network Management (PNM): The Maximus-operated portal for Medicaid enrollment https://ohpnm.omes.maximus.com
• Ohio Department of Aging (ODA): Administers the PASSPORT waiver https://aging.ohio.gov

3. Gatekeeping Prerequisites: Who Can Even Apply

Ohio requires all agencies providing skilled nursing services in the home to hold an active Home Health Agency license issued by ODH. This state license is a strict prerequisite before any Medicaid enrollment application can be initiated.

Furthermore, to bill Medicaid for standard Home Health Nursing, the agency must be a Medicare Certified Home Health Agency (MCHHA). Agencies providing Private Duty Nursing or Waiver Nursing must hold national accreditation if they are not Medicare certified.

• ODH Licensure: Mandatory state license required before Medicaid enrollment for all home health agencies.
• Medicare Certification: Required to bill standard Medicaid Home Health services (must be an MCHHA).
• National Accreditation: Agencies providing PDN or Waiver Nursing must hold accreditation from ACHC, CHAP, or the Joint Commission if not Medicare certified.
• NPI Assignment: A National Provider Identifier (NPI) from NPPES must be obtained prior to PNM enrollment.

4. Licensure and Certification Requirements

Agencies must submit an initial license application to ODH and pass a readiness survey. The ODH license must be maintained continuously to operate legally in Ohio.

Following state licensure, agencies must complete the Medicare certification process or obtain accreditation from an approved national body to meet ODM's provider qualifications.

• Application Form: ODH Home Health Agency initial license application.
• Licensure Fee: Required fee submitted to ODH with the initial application (typically $250).
• Readiness Letter: Must be submitted to ODH prior to Medicaid enrollment.
• Accreditation Window: Must maintain active accreditation from an approved national body (ACHC, CHAP, Joint Commission) per OAC 5160-12-03.1.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed exclusively through the Provider Network Management (PNM) module. Agencies must upload their ODH license, Medicare certification or accreditation, and tax documents.

Providers are required to revalidate their Medicaid enrollment every three years, with notices sent via the PNM system 120 days prior to expiration.

• System: Provider Network Management (PNM) module.
• Required Documents: W-9, NPI notification from NPPES, ODH license, and Medicare certification/accreditation proof.
• Application Fee: Medicaid application fee (tied to CMS rate) unless paid directly to Medicare.
• Revalidation: Required every 3 years (120-day notice provided in PNM).

6. Staffing, Training and Background Checks

Skilled nursing services must be delivered by nurses holding active, unrestricted licenses in Ohio. LPNs must practice under the direct supervision of an RN.

All staff must undergo comprehensive background checks through the Ohio Bureau of Criminal Identification and Investigation (BCI) prior to client contact.

• RN Qualifications: Active, unrestricted Ohio Registered Nurse license.
• LPN Qualifications: Active Ohio Licensed Practical Nurse license, practicing under RN direction.
• Background Checks: Mandatory Ohio Bureau of Criminal Identification and Investigation (BCI) check.
• Federal Checks: FBI background check required if the applicant has lived in Ohio for less than 5 years.

7. Documentation, Policies and Records

Agencies must maintain detailed clinical records, including signed physician orders and documented face-to-face encounters. Services must align exactly with the approved person-centered services plan.

Records must be retained securely and made available for state audits or ODH surveys upon request.

• Physician Orders: Must be signed and dated by the treating physician.
• Face-to-Face Encounter: Documented within 90 days prior to or 30 days after the start of care.
• Service Plan: Services must be explicitly listed on the ODM, ODA, or DODD person-centered services plan.
• Record Retention: Clinical and billing records must be retained for a minimum of 6 years.

8. Billing, Rates and Claims

Claims for skilled nursing services are submitted through the PNM module or an approved clearinghouse to the Ohio MMIS. Rates are established by ODM and published in the provider fee schedule.

Specific modifiers are required to indicate increased services or specific waiver authorizations, and prior authorization is required for services exceeding standard limits.

• Billing System: Claims submitted through the PNM module to Ohio MMIS.
• Modifiers: U5 modifier used to indicate increased home health services for qualifying individuals.
• Prior Authorization: Required for Waiver Nursing services exceeding standard state plan limits.
• Discharge Documentation: Form ODM 07137 required for post-hospital stay home health billing.

9. Approval Sequence and Timeline

The approval process is strictly sequential. An agency cannot apply for Medicaid enrollment until it has secured its ODH license and either Medicare certification or national accreditation.

The entire process from entity formation to billing the first Medicaid claim typically takes 9 to 12 months, heavily dependent on accreditation survey timelines.

• Step 1: Obtain ODH Home Health Agency license (approx. 3-6 months).
• Step 2: Achieve Medicare Certification or National Accreditation (approx. 6-9 months).
• Step 3: Submit Medicaid enrollment via PNM module.
• Step 4: MCO Credentialing (required for managed care billing, adds 90-120 days).

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to missing prerequisites, such as attempting to enroll in PNM without an active ODH license or proof of accreditation.

During surveys, the most common citations involve clinical documentation errors, particularly missing physician signatures or late face-to-face encounter documentation.

• Missing Face-to-Face: Failure to document the physician encounter within the required 90/30 day window.
• Unapproved Plans: Billing for services not explicitly documented on the prior-approved person-centered services plan.
• Lapsed Accreditation: Failure to maintain active ACHC, CHAP, or Joint Commission accreditation.
• Background Check Gaps: Missing FBI checks for staff with less than 5 years of Ohio residency.

11. Key Contacts and Resources

Providers should rely on the official state portals and administrative code for the most current regulations and fee schedules.

The PNM help desk and ODH licensure division are the primary contacts for application status inquiries.

• Ohio Department of Health (ODH): https://odh.ohio.gov
• Ohio Department of Medicaid (ODM): https://medicaid.ohio.gov
• Provider Network Management (PNM) Portal: https://ohpnm.omes.maximus.com
• Ohio Administrative Code (OAC) 5160-12: Home Health Services rules https://codes.ohio.gov

See all Ohio services · Ohio Medicaid consulting · book a consultation.