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Avoid claim denials – make your PNM updates before October 20
Effective October 20, Next Generation Medicaid managed care organizations (MCO), the OhioRISE plan, and MyCare Ohio plans, must use provider data from Ohio Medicaid’s Provider Network Management (PNM) module as it is the official system of record. To ensure the provider data sent from the PNM to the managed care entities (MCE) is accurate and up to date, it is imperative that your records are updated within the PNM daily. If your data in the PNM module does not match your data on the submitted claim, your claims will be denied for payment.
Actions needed by you as a provider or a trading partner
- Check that all data submitted on a claim and within the PNM module (e.g., addresses, affiliations, specialties, locations) is accurate and up to date.
- Access Provider Education & Training Resources within the PNM ‘Learning’ tab for step-by-step instructions.
- Continue to update data as changes occur. MCEs will use this information as the system of record moving forward.
The MCEs download a complete extract of the Provider Master File (PMF) daily that includes all provider data.
You can read the full announcement here.
If you need assistance, please feel free to reach out to AmeriHealth Caritas Ohio's Provider Services at 1-833-644-6001, and as always, you can reach out to your local account executive.
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When should the provider submit an Appeal vs. Dispute? |
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Appeal
The appeal process can be followed if a claim has NOT been submitted. If a provider submits an authorization for services, but the authorization denies, the provider should file an appeal. If the provider has seen the member and provided the services, but not yet submitted the claim, they would still follow this appeal process. All providers can fax their appeals information to 1-833-329-2164.
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Dispute
Provider claim disputes are any provider inquiries or requests for reconsideration about a filed claim, ranging from general questions to a provider disagreeing with a claim denial. A dispute can be submitted using any of the following methods:
Phone: 1-833-644-6001 (select the prompts for the correct department and then select the prompt for claim issues) Fax: 1-833-216-2272.
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NaviNet is an easy-to-use, no-cost, secure web-based platform that links providers to AmeriHealth Caritas Ohio. NaviNet helps speed up the provider-health plan connection and can replace paper transactions. Through NaviNet, you can access and submit:
- Prior authorizations
- Real-time clinical Healthcare Effectiveness Data and Information Set (HEDIS) alerts
- Claims information and updates
- Member eligibility information
- Benefits information
- Drug authorizations
NaviNet allows providers and health plans to share administrative, financial, and clinical data in one place. If you haven’t signed up for NaviNet yet, be sure to register.
Prior authorizations
Did you know you can submit prior authorizations through the NaviNet portal?
AmeriHealth Caritas Ohio created this tool to provide a higher auto-approval rate and quicker turnaround time compared to faxing the authorizations. There is also a report function that gives a status report allowing you to have visibility to all prior authorization requests you have submitted.
We are happy to offer training or any assistance your team may need to transition to this process. Please reach out to your local Account Executive. Click here to log into NaviNet.
NaviNet dispute process
Provider claim disputes are any provider inquiry or request for reconsideration. They range from general questions about a claim to a provider disagreeing with a claim denial.
Disputes can be filed directly with NaviNet using any of the following methods:
- Phone: 1-833-644-6001 (select the prompts for the correct department and then select the prompt for claim issues)
- Online NaviNet
- Mail:
AmeriHealth Caritas Ohio
Attn: Provider Claim Inquiry
P.O. Box 7104
London, KY 40742
- Fax: 1-833-216-2272
Click here to watch a tutorial video with step-by-step instructions on how to file a claim. Access the Provider Dispute Submission Form
Tools in NaviNet - Medicaid Member Annual Eligibility Redetermination
In an effort to help ensure that AmeriHealth Caritas Ohio members continue to receive Medicaid benefits from the Ohio Department of Medicaid, AmeriHealth Caritas Ohio has launched two new tools in the NaviNet provider portal that will allow providers to view upcoming Medicaid Member Annual Eligibility Redetermination (Recertification) dates.
The following tools are available in the NaviNet Provider Portal:
- Medicaid Member Annual Eligibility Redetermination Popup Alert
In the Eligibility and Benefits Screen under the Patient Alert Details popup, there will be a new “Redetermination Report” link that, when clicked, will display the member’s upcoming eligibility redetermination date. The new pop-up alert will be very similar to the existing Care Gap and PCP History alerts and will be available to all provider types.
- Medicaid Member Annual Eligibility Redetermination Report
In the Administrative Report Inquiry section, a new report will be available for PCPs under the report list dropdown that provides a full list of all members on your roster who have upcoming eligibility redetermination dates. The report will be available for PCPs to download in both PDF and excel formats.
Call to action
You can use these new tools to verify AmeriHealth Caritas Ohio members (your patients) Medicaid Annual Eligibility Redetermination status. If you receive an alert or report in NaviNet that indicates your plan member has an upcoming eligibility redetermination date, you can help ensure their continued coverage by stressing the urgency of timely recertification and directing those in need of assistance to us at 1-833-764-7700 (TTY 1-833-889-6446).
Timely recertification is important because it:
- Helps ensure continuity of care for our plan members/your patients.
- Eases administrative burden when verifying member eligibility.
- Avoids the need for resubmission of prior authorization requests for certain services that may be required due to gaps in care caused by lapsed Medicaid coverage.
- Supports timely deeming of newborns as Medicaid eligible and ensures mom and baby are both on the AmeriHealth Caritas Ohio plan.
If you have any questions, please feel free to contact your AmeriHealth Caritas Ohio Provider Account Executive or Provider Services at 1-833-644-6001. AmeriHealth Caritas Ohio members who require assistance should be directed to us at 1-833-764-7700 (TTY 1-833-889-6446).
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New form required when requesting an Administrator change across organizations
Ohio Department of Medicaid (ODM) developed a new form, ODM10304, that must accompany requests to change Provider Network Management (PNM) Administrators from one billing organization provider to another. As a security measure, you must submit a formal request to transfer Administrator ownership of a Medicaid ID within the PNM module. More details are available on ODMs website.
Claim submission and adjudication FAQ is now available
ODM updated the Claims and Prior Authorization Submission Frequently Asked Questions (FAQ) to make it easier for you to find the information you need. It covers fee-for-service, managed care, and OhioRISE billing procedures, adjudication processes, and other answers to common provider questions. Review this document on the submitting claims and prior authorizations page on the Next Generation website and share it within your practice or organization.
If you have questions, providers can contact the ODM Integrated Helpdesk (IHD) at 1-800-686-1516 or IHD@medicaid.ohio.gov. Representatives are available 8 a.m. - 4:30 p.m. Eastern time Monday - Friday.
Updated HEDIS Guidelines for the Care Gap Closure program
Click here to view the HEDIS 2023 Documentation and Coding Guidelines.
Ohio Department of Medicaid fraud warning
Criminals are targeting Medicaid recipients for sensitive, personal, and financial information. If your patient gets a call, text, or email about Medicaid benefits asking for a Social Security number, payment, bank, debit, or credit card information, advise your patient to not respond. They’re not from the State of Ohio or any agency. Instead, it should be reported to the Ohio Attorney General at 1-800-282-0515 or click here.
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The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). If you have submitted a paper claim, you will be advised that your claim has not been processed and what your next steps should be. You can get started on our website with claims how-tos, quick guides, links and contact info. |
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Provider Claims and Billing Manual - Box 33, no PO Box allowed
33 Billing Provider Info & Ph. # Required – Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable R 2010AA NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04
See page 17 of Provider Claims and Billing Manual.
Important requirements for Hospice Billing of (HCPC T2046) and Ventilator/Ventilator Weaning Services
- Hospice Nursing Facility R&B should be billed on a HCFA form. Be sure to include the name of the facility where services were rendered in box 32a.
- Vent and Vent weaning claims should be billed on a UB form with Type of bill 81X/081X. If this bill type is not used the claim will deny.
- On Vent and Vent weaning claims, the diagnosis of Z99.11 should be present.
- Vent and Vent weaning claims require the provider to include the name and NPI of the NF where services were rendered in box 80 (Remark code).
If the above conditions are not met, the claim may be denied and require submission of a corrected claim.
Access and Availability Standards
As part of ongoing network management, periodic outreach to confirm maintenance of access and availability standards does occur. The specific access time frames are determined by the provider type of the service, and is outlined starting on page 34 of the AmeriHealth Caritas Ohio Provider Manual.
Do not send paper claims
The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). If you have submitted a paper claim, you will be advised that your claim has not been processed and what your next steps should be. You can get started on our website with claims how-tos, quick guides, links and contact info.
Medicaid Annual Eligibility Redetermination Reviews
Information for providers regarding Annual Eligibility Redetermination Reviews is on our website. This federally required process is in place to ensure those enrolled in Medicaid programs continue to meet established eligibility criteria. AmeriHealth Caritas Ohio will collaborate with Ohio Department of Medicaid and our provider network to minimize the burden on our members and promote continuity of health coverage.
Access AmeriHealth Caritas Ohio's provider resources
Step 1: Visit our provider webpage
Step 2: Sign up for NaviNet
Step 3: Attend a Provider Orientation Meeting
Step 4: Submit claims through Electronic Data Interchange (EDI)
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Virtual office hours
Got Questions? Let us help you. Join the ACOH Provider Services team for a virtual office hours. Our team will be here to help answer your questions or help you navigate our provider resources. We will be offering virtual office hours with no registration necessary.
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Claims Payment Systemic Error (CPSE) report
The Claims Payment Systemic Errors (CPSE) report is updated and posted on the ‘Alerts and Newsletter’ page monthly. AmeriHealth Caritas Ohio encourages you to review this log frequently and before contacting our Provider Services team. If after reviewing you still have additional questions, please feel free to reach out to Provider Services at 1-833-644-6001 and, as always, you can reach out to your local account executive.
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Tell us a little bit about where you’re from.
I grew up in Dublin, Ohio and attended Bishop Watterson High School. I graduated from the University of Kentucky with a B.A. in Political Science in the winter of 2022.
Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours?
I finished my studies over the summer and was waiting to graduate in the winter, and knew that I was coming to the close of a huge chapter of my life. I began looking for what my next step would be. Considering my studies, I instinctively began looking for careers working with or near the government, where I found little opportunity. While talking about job hunting, a family member and I were speaking about the upcoming changes to Medicaid, and they suggested I should look at the new managed care organizations. After interviewing and meeting the team, I knew I had found a great fit for me.I am excited to have been here for nearly a year.
What drew you to this profession?
Coming out of school, I wanted to find more than just a job. For me that meant it had to be something that I could be passionate about. I knew I wanted to work somewhere where I could help people, and the manner in which we try to work with our providers keeps me engaged and in touch with our providers. I love being more than just an email address for our providers, and look forward to hearing from them.
What do you like to do in your free time?
I try to get out of the house and stay active. I play soccer, rock climb at a local gym, and spend time with my friends.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
I would love to have dinner with General Dwight D. Eisenhower. I love history, but have always found it much more interesting |
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when I could see the personalities of historical figures. I would be fascinated to sit down and have a conversation with him. As General, and later President, Eisenhower he was involved in some of the most important events of the 20th century, and the people he worked with the had the personalities to match. Eisenhower had to work with some of the most fascinating historical figures of all time. I would love to speak with him about what it was like to make such difficult decisions and the different personalities he had to work with.
What are two apps on your phone you CANNOT live without?
Audible and Discord. I love to listen to audio books throughout the day. I have 70 books and I’m always looking for more to add. Discord is how I keep in touch with my friends. After graduation my fiends have really spread out across the U.S. Discord has been the best way for us to keep in touch when we can only see each other a few times a year.
Any interesting facts about yourself that you’d like to share?
During my first year at UK, they held the world’s largest water balloon fight with 750,000 water balloons and thousands of students.
Me at the USA vs.Costa Rica World Cup qualifying match
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My contact info and territory: Brent Frank
Counties: Ashland, Crawford, Marion, Morrow, Richland and Wyandot
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Join us for Coffee and Conversations with AmeriHealth
Stop by any of these locations as you head into work. Get to know your Account Executives and ask any questions you may have. The coffee is on us!
Friday, Oct. 27, 7:30 a.m. - 9:30 a.m.
Starbucks Eastgate, 2120 Harding Highway, Lima
Thursday, Nov. 2, 7:00 a.m. - 9:00 a.m.
Sip Coffee, 3160 Markway Road, Toledo
Thursday, Nov. 2, 8:00 a.m. - 10:00 a.m.
Lofts Coffee, 842 Gallia Street, Portsmouth
Friday, Nov. 3, 8:00 a.m. - 10:00 a.m
Donkey Coffee, 17 W. Washington Street, Athens
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We would love to hear from you!
Your voice matters and we want to hear your thoughts regarding participation in AmeriHealth Caritas Ohio's Population Health and Quality initiatives. Click here to take the one-minute survey.
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October is Benefits of Youth Sports Month |
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The National Youth Sports Strategy aims to unite U.S. youth sports culture around a shared vision: that one day, all youth will have the opportunity, motivation, and access to play sports.
Learn more here about research, best practices, and successful youth sports programs.
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Some of the mental and physical benefits of playing youth sports:
- Make new friends
- Improve academic potential
- Improve mental health
- Improve emotional regulation
- Understand teamwork
- Build leadership skills
- Keep kids active
- Less time on technology
- Develop motor skills and coordination
- Increase flexibility and range of motion
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New provider orientation sessions are available through the rest of the year
We encourage providers to attend one of our new provider orientations. This ODM-required presentation offers us the opportunity to introduce ourselves to new providers. These presentations include information on our unique member benefits, value-based care program, claims and billing information and our provider portal NaviNet. Join your personal account executives online via Zoom from 10 a.m. - 11 a.m. on any of the dates below.
October 17 - click here to register
November 14 - click here to register.
December 19 - click here to register
We encourage you to register to attend one of these online webinars or to contact your local Account Executive to schedule an individual orientation
If you attended an orientation session and need to complete the attestation, click here to get started.
Improving Outcomes for People with Disabilities 2023 virtual roundtable
Ohio Association of Health Plans and Ohio Center for Autism and Low Incidence (OCALI) are hosting a series of virtual roundtables. This series provides attendees the opportunity to hear from and engage with national experts and local leaders and deepen their understanding of people with disabilities as a focus of population health. The one-hour roundtables include lived experience, didactic presentation, and opportunity for interaction. Each session is designed to both challenge your thinking and change your practice, providing you with tools and resources you can use immediately.
- October 24 - Economic Stability: Employment
- November 28 - Social & Community Context: Family Caregivers
Continuous Glucose Monitors Learning Series
Continuous Glucose Monitors (CMGs) are associated with improved Hemoglobin A1c levels in adults with Type 2 diabetes covered by Medicaid. To improve outcomes for patients with diabetes, the Medicaid Managed Care Plans have removed Prior Authorization requirements for CGMs ordered through pharmacy or Durable Medical Equipment channels. AmeriHealth Caritas and other Medicaid Managed Care Plans are working with providers to integrate CGMs into their practice and are available to work with you. If you are curious about how to use CGMs in your practice, please consider participating in this educational series offered by Dexcom. It is free of charge for providers and their staff. AmeriHealth associates are always available to partner with you and your practice to improve the care for your patients with diabetes.View the schedule and register here.
Ask a Sandata trainer
Do you have questions about Electronic Visit Verifications (EVV)? You can schedule a private Zoom session with a Sandata trainer to discuss your EVV questions. Sessions are available Monday - Friday at 10:00 a.m. and 2:00 p.m. If these times do not work with your schedule, please reach out to odmevvtraining@sandata.com.
The following concepts are addressed in the sessions:
- Improving EVV claims matching
- Solving reoccurring exceptions
- Getting started with EVV
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