Effective 09.01.2024, the medications below will require a prior authorization (submitted by your prescriber) if there is not already an active prior authorization on file:
Prescribers may submit a prior authorization by electronic request, by faxing Gainwell Pharmacy Services at 833-679-5491, or by calling 833-491-0344 (TTY 833-655-2437). Prior authorizations are processed within 24 hours of receipt.
Prior authorization submissions for the medications above will be reviewed per the Ohio Medicaid Unified Preferred Drug List (UPDL) clinical criteria. You can find more information about prior authorizations for these medications by visiting https:\\spbm.medicaid.ohio.gov. Choose “Reference Material", then “Unified Preferred Drug List", and then “UPDL criteria effective 07.01.2024" from the list of documents.
06/30/2023
Beginning on July 1, 2023, in addition to Ohio Medicaid Managed Care, Gainwell Technologies will be the Single Pharmacy Benefit Manager (SPBM) for Ohio Medicaid Fee for Service. ODM's continued goal for the SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through the SPBM, ODM gains increased accountability and ensures alignment with clinical and policy goals, while also improving transparency.
A Frequently Asked Questions (FAQ) for pharmacies servicing FFS members is available here: SPBM FFS Provider FAQ
06/30/2023
Are you a pharmacy or prescriber having issues registering for the secure SPBM Web Portal? Gainwell is offering several options available below for your assistance:
06/30/2023
The SPBM Web Portal training recording is now available for all enrolled Ohio Medicaid Members!
For Member training registration instructions, click here.
If you have any questions regarding SPBM Web Portal training, please email OH_MCD_PBM@gainwelltechnologies.com
06/30/2023
Pharmacy Web Portal training recording now available
The recorded SPBM Web Portal training is now available for pharmacies and pharmacy support staff. Viewing this training is important for pharmacists and their support staff to learn about the many tools available on both the public facing and secure portal. The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria. The secure portal requires log in credentials. It provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email.
To access the recording, please click here. Please use the same Learning Management System (LMS) credentials set up during your registration to log in.
Prescriber Web Portal training recording now available
The recorded SPBM Web Portal training is now available for prescribers and prescriber support staff. Viewing this training is important for pharmacists and their support staff to learn about the many tools available on both the public facing and secure portal. The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria. The secure portal requires log in credentials. It provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email.
To access the recording, please click here. Please use the same Learning Management System (LMS) credentials set up during your registration to log in.
Gainwell Technologies and the Ohio Department of Medicaid (ODM) launched the Single Pharmacy Benefit Manager (SPBM) on October 1! Gainwell has already contracted with more than 2600 pharmacies. ODM's goals for the SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through the SPBM, ODM gains increased accountability and ensures alignment with clinical and policy goals, while also improving transparency.
Questions?
Pharmacy providers and members may contact the Gainwell Customer Support Center by phone 833-491-0344, 24 hours a day, seven days a week. The Customer Support Center is closed on Thanksgiving Day and Christmas.
Managed Care Entity Web Portal training recording now available
The recorded SPBM Web Portal training is now available for Managed Care Entity Portal Administrators and staff. Viewing this training is important for managed care entities to learn about the many tools available on both the public facing and secure portal. The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria. The secure portal requires log in credentials that will allow access to specific patient information. The portal also gives the user the ability to reach the SPBM Clinical help desk via web chat.
To access the recording, please click here . Please use the same Learning Management System (LMS) credentials set up during your registration to log in.
05/01/2022
Welcome to the new Ohio Medicaid pharmacy services online portal.
This is a soft launch of the SPBM online portal with limited features.
Thank you for your patience as we continue to enhance the system.
Register today for SPBM Web Portal training!
Registration for SPBM Web Portal training is now open for all members.
Please join the Gainwell Ohio SPBM training staff to learn the difference between the public and the secure portals, including how to register for the secure portal. During the training, you will also learn about many exciting tools available on the SPBM Web Portal such as member eligibility, viewing prior authorization status, the ability to quickly speak with the SPBM help desk, and much more!
Members will have access to a training video on Oct. 1. For training registration instructions, click here.
To allow providers an advanced opportunity to set up their OH|ID and associate their accounts, ODM has launched a PNM pre-registration site at: https://pnm-preregistration.omes.maximus.com. The PNM Pre-Registration tool is available until Sept. 23 and will ease the transition and prevent disruptions to system access for providers ahead of go-live on Oct. 1. Additionally, PNM training is now available for providers in a variety of formats, including virtual, in-person, and self-paced. Please access this job aid for step-by-step instructions to sign up for a session.
Managed Care Entities (MCE) including Managed Care Organizations (MCO) and the Prepaid Inpatient Health Plan (PIHP), which is also known as OhioRISE, will be given access to the SPBM online portal to view clinical profile information about members that are actively enrolled in their associated MCE.
Clinical information that is available includes member benefit and eligibility, pharmacy prescription claims activity, Rx prior authorizations, and Coordinated Services Program (CSP) status will be distributed to the MCEs, however, the portal will allow quicker access to the most current information.
Report Fraud Waste and Abuse
Compliance Hotline: 1-833-220-9970
Website: https://spbm-medicaid-ohio.ethicspoint.com/
Email: OH_MCD_Compliance@GAINWELLTECHNOLOGIES.COM
All reports are investigated and remain confidential to the extent permitted by law. To help us investigate please include a detailed description of the activity and include:
•Provider/Member/Employee name and number (if you have a number available)
•Date of activity or incident
•As much detail about your concern as possible and any relevant information you have.
Reports made via the Compliance Hotline or Website may be done so anonymously. Please note that reporting via email is not anonymous.
The Compliance Hotline and Website are administered by EthicsPoint. Please click the link for Frequently Asked Questions to learn more about EthicsPoint.
Additional Reporting Options:
You may report any potential fraud, waste, or abuse activities directly to the State of Ohio using one of the following options:
Ohio Department of Medicaid
Phone: (614) 466-0722 or toll free 1-800-324-8680
Website: Reporting Suspected Medicaid Fraud | Medicaid (ohio.gov)
Ohio Medicaid Fraud Control Unit (MFCU)
Fax: 1-877-527-1305
Website: Report Medicaid Fraud - Ohio Attorney General Dave Yost
You may report any potential fraud, waste, or abuse activities directly to the Federal Government
U.S. Department of Health and Human Services, Office of the Inspector General
Toll Free 1-(800) 447-8477
Website: https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx
Gainwell is committed to protecting the integrity of the Ohio Medicaid Program. Medicaid fraud, waste, and abuse (FWA) negatively impacts our members, providers, and community. Gainwell has invested in a comprehensive program to prevent, detect, and report any potential fraud, waste, or abuse activities. You can help us by reporting any suspicious activity and we will investigate each report to ensure the Ohio Medicaid Program is protected .
Understanding FWA is key to prevention and detection. You will find the definitions and examples below.
Fraud
An intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. To be considered fraud the act must demonstrate that a person or entity knowingly submitted, or caused to be submitted, false claims or misrepresentations of fact to obtain a government funded health care payment for which no entitlement would otherwise exist.
Examples of Medicaid Fraud:
·Intentionally billing for unnecessary medical services or items
·Intentionally billing for services or items not provided
·Unbundling: billing for multiple codes for a group of procedures that are covered in a single global billing code
·Upcoding: billing for services at a higher level of complexity than provided
·Card sharing: knowingly treating and claiming reimbursement for someone other than the eligible beneficiary. Member sharing their Medicaid ID card with someone else so they can obtain medical services.
·Collusion: knowingly collaborating with beneficiaries to file false claims for reimbursement. Members helping their doctors file claims by having tests done you do not need.
·Drug Diversion: writing unnecessary prescriptions or altering prescriptions to obtain drugs for personal use or to sell them. Member altering a doctor's prescription, going to multiple doctors to get more of the same drug, or selling their drugs to others.
·Kickbacks: offering, soliciting, or paying for beneficiary referrals for medical services or items. Members accepting payment from their doctor for referring other beneficiaries for medical services.
·Multiple cards: knowingly accepting multiple Medicaid ID cards from a beneficiary to claim reimbursement. Members altering or duplicating their Medicaid ID card and using it or selling it for someone else to use.
·Program Eligibility: Knowingly billing for an ineligible beneficiary. Member providing incorrect information to qualify for Medicaid.
Waste
Practices that directly, or indirectly result in unnecessary costs such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Examples of Medicaid Waste
·Conducting excessive office visits or writing excessive prescriptions
·Prescribing more medications than necessary for treating a specific condition
·Ordering excessive laboratory tests
Abuse
Abuse includes practices that are inconsistent with professional standards of care; medical necessity; or fiscal, business, or medical practices; and that constitute an over utilization of Medicaid covered services and result in an unnecessary cost to the Medicaid program. These can be actions that may directly or indirectly result in unnecessary costs. Abuse involves paying for items or services when there is no legal entitlement to that payments, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.
Examples of Medicaid Abuse
·Unknowingly billing for unnecessary medical services
·Unknowingly billing for brand name drugs when generics are dispensed
·Unknowingly excessively charging for services or supplies
·Unknowingly misusing codes on a claim such as upcoding or unbundling codes
Compliance Hotline / EthicsPoint FAQ
Do you suspect Fraud, Waste, or Abuse?
As Ohio's Medicaid Pharmacy Benefit Manager, Gainwell is committed to the prevention and detection of fraud, waste and abuse.
Medicaid can be misused by prescribers, pharmacies, members, contractors, or others. The information contained within this FAQ is intended to help guide you in our process for reporting suspected fraud, waste, and abuse.
What is Ethics Point?
EthicsPoint is a comprehensive and confidential reporting tool created by NAVEX that enables Gainwell and the Ohio Department of Medicaid to work together to address reports of suspicious or irregular actions by a pharmacy, prescriber or beneficiary.
Who is responsible for identifying fraud, waste, and abuse?
Anyone who participates in the Ohio Medicaid Program. This includes but is not limited to:
• Members/beneficiaries
• Prescribers and Pharmacies
• Contractors
• Managed Care Organizations
• Pharmacy Benefit Managers
What is fraud, waste & abuse?
Fraud is the intentional deception, false statement, or misrepresentation made by a person with knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable Federal or State law. Waste and abuse are practices that are inconsistent with professional standards of care; medical necessity; fiscal business, or medical practices; and that constitute an over utilization of Medicaid covered services and result in an unnecessary cost to the Medicaid program.
Examples of Prescriber Fraud Waste and Abuse:
• Billing for services, procedures, prescriptions, and/or supplies that were not provided or rendered
• Intentionally billing for services or items not provided
• Upcoding: billing for services at a higher level of complexity than provided
• Purchasing drugs from outside the U.S.
• Prescribing high quantities of controlled substances without medical necessity
• Prescribing drugs, equipment, or services that are not medically necessary
Examples of Member Fraud Waste and Abuse:
• Sharing a member ID card
• Selling prescribed medications
• Seeking controlled substances from multiple prescribers or pharmacies
• Altering or forging prescription forms
• Adding ineligible people to beneficiary plan
• Falsification of information to obtain benefits such as on enrollment forms or medical documentation
Examples of Pharmacy Fraud Waste and Abuse
• Submitting claims for a more expensive brand name drug when generic drug is available
• Not dispensing prescriptions as written. Such as dispensing less than quantity prescribed without notification to the member or provider.
• Billing for prescriptions that were not filled or picked up by the member
• Dispensing expired, diluted, altered, or illegal drugs
Can I report Gainwell of suspected of fraud, waste, and abuse or other unethical or inappropriate behavior (as Ohio's Medicaid Pharmacy Benefit Manager)?
Yes. Gainwell is committed to our strong values of responsibility and integrity. Gainwell wants you to feel comfortable raising concerns of potential fraud, waste, and abuse. Additionally, Gainwell encourages reporting of concerns of potential violations of law, policy, and other misconduct.
Can I report suspected fraud, waste, and abuse directly to the State or Federal government?
Yes. Suspected cases of fraud, waste, and abuse may also be reported to the applicable regulatory State or Federal agency.
Can I report anonymously?
Yes. Please remember to provide as many details as possible regarding your concern and a clear description of what you believe has happened. The information you provide is important and Gainwell is unable to follow up with an anonymous source for details or clarification, so Gainwell asks that you provide as much information as possible to perform a thorough investigation of your concern.
Where do these reports go and who can access them?
Reports are entered directly onto NAVEX's EthicsPoint secure server. NAVEX makes these reports available only to specific team members within Gainwell's Fraud, Waste, and Abuse Department, who will only provide these reports to the Ohio Medicaid Program Integrity Unit if fraud is identified. Your report will be kept confidential as provided by applicable Federal and State laws.
The following resources and policies should be place on this page.
Gainwell OH SPBM Fraud Waste and Abuse Policy
EthicsPoint FAQ