Welcome to the November newsletter
November 2023

Have you received a 2023 Provider Satisfaction Survey in the mail?
If your practice was one of the randomly selected providers to receive the annual provider satisfaction survey for AmeriHealth Caritas Ohio (mailed from Press Ganey), please take the time to fill out and return it. If you haven't completed the survey, you may receive a phone call. Please take the time to talk to the surveyor. We count on your feedback to let us know how we are doing and where we need to improve.


Remember, the survey is anonymous and your opinions are important to us! Thank you in advance for taking the time to participate.

Did you know you can now submit all medical pharmacy prior authorizations online?

Our online PA request form is fast, easy, and, best of all, requires no user IDs or passwords. Remember to bookmark the page for future reference.


AmeriHealth Caritas Ohio is pleased to announce the launch of our new and improved NaviNet Plan Central page. Still the same great tool, but just with a new look. Here are some of the key enhancements you will experience with our new design:

  • Fresh new look with larger text sizes for easier reading
  • Cleaner layout for improved navigation
  • Better organization of topics for quicker access to key information

We encourage you to check out the new NaviNet Plan Central page by logging in to NaviNet. If you aren’t signed up for NaviNet yet, click here to register for this important tool.


If you have any questions, please contact your Provider Network Account Executive. Thank you for your continued partnership and for the valuable services you provide our members.


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 a 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  


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 reach out to NaviNet directly for assistance.

The importance of the SL modifier in childhood vaccines

Vaccines for Children (VFC) Program

AmeriHealth Caritas Ohio primary care physicians (PCP) are required to enroll with the Ohio Department of Health (ODH) Immunization Program to receive vaccines for members under age 19 years through the Vaccines for Children Program. Vaccinations covered by the VFC program will not be reimbursed by AmeriHealth Caritas Ohio; however, the Plan reimburses providers for appropriate vaccine administration to members aged 18 years and younger. Providers are expected to plan for a sufficient supply of vaccines and are required to report the use of VFC vaccines immunizations by:

  • Use the “SL” modifier to indicate the provider is participating in the program
  • The SL modifier must be listed on the vaccine line of the claim and will result in no reimbursement.
  • Providers will receive reimbursement for the administration of the vaccine only


In July of 2023 the FDA approved Nirsevimab (Beyfortus) for RSV prevention.  Nirsevimab (Beyfortus)   contains monoclonal antibodies providing passive immunity protection for your patients.  One dose of Nirsevimab (Beyfortus) administered as a single intramuscular injection prior to or during RSV season, may provide protection during the RSV season. 


Nirsevimab is covered under VFC. The Centers for Disease Control recommends the following:

  • Nirsevimab is recommended for infants younger than 8 months of age who were born during or are entering their first RSV season if:
    • The mother did not receive RSV vaccine during pregnancy
    • The mother’s RSV vaccination status is unknown.
    • The infant was born within 14 days of maternal RSV vaccination.

Most infants whose mothers got the RSV vaccine don’t need to get nirsevimab, too.

  • Some infants and young children 8 through 19 months of age who are at increased risk for severe RSV disease should receive nirsevimab shortly before the start of their second RSV season:
    • Children who were born prematurely and have chronic lung disease
    • Children with severe immunocompromise
    • Children with cystic fibrosis who have severe disease
    • American Indian and Alaska Native children

Children who should get nirsevimab but have not yet done so, may get nirsevimab at any time during RSV season.

When should the provider submit an Appeal vs. Dispute?
To assist in reducing misrouted appeals and ensure that we are handling all appeal requests timely, provider's should review their provider manual to ensure you are sending member/providers appeals to the correct department. We have received misrouted appeals being sent to the provider claims disputes area. Please refer to your manual to understand the differences in the processes of requesting a member/provider appeal and a provider claim dispute. 






Reminder: Update addresses and affiliations in the Provider Network Management (PNM) module

It is imperative that providers update all address and affiliation information in the PNM so that claims payments, provider directories, and network adequacy measurements are not negatively impacted. Click on the following links for step-by-step instructions on how to complete these actions.

Updating or adding owner information

Updating or adding practice locations

Updating or adding a specialty in PNM


Fee Schedules

As part of our Next Generation program transition, Ohio Department of Medicaid (ODM) has transitioned our fee schedules from the Fiscal Intermediary (FI) to the Provider Network Management (PNM) portal. ODM is working to include corrections to the posted fee schedules. Please be advised that in the meantime, providers can access the correct fee schedule at Schedules and Rates. Note: Adjustments may be made for any incorrect payment rates.


Incomplete PNM affiliation steps may impact provider billing

Through a series of PNM queries, Ohio Department of Medicaid (ODM) has identified several affiliation issues that impact billing organizations claims. It is imperative that providers fully execute all steps when affiliating a rendering provider to their group/organization/hospital to avoid claims payment issues. An Affiliations Quick Reference Guide (QRG) has been created, showing step-by-step instructions and information related to entering an affiliation as a new individual practitioner; confirming, adding, and removing an individual practitioner’s affiliation as a group or organization.


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


Quick email links

Resources and reminders
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. 
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 PER04See page 17 of Provider Claims and Billing 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.
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.  
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)
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. 
November 16, Noon - 1:00 p.m. click to join

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.

Tell us a little bit about where you’re from. I am from Wapakoneta. I graduated from Shawnee High School, then went on to Lima Technical College for my Associates Degree in Nursing and my Bachelors in Nursing from University of Phoenix.


Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours? I was researching a job that could get me away from the bedside and behind the scenes with an insurance company.  Once I found the job as an Account Executive for ACOH I felt that this is something that I could do to make a difference for the members by getting the information to the providers about all the added benefits that AmeriHealth Caritas Ohio has to offer. This was also an opportunity to get more work/life balance. I am a true believer that you are a better employee with the ability to find that balance in your life.   


What drew you to this profession?

As a nurse I feel that knowing all the ins and outs of healthcare makes you a better nurse and that is what this profession was going to help me do.
What do you like to do in your free time? Spending time with family is the number one thing that I love to do. But when that isn’t an option, learning piano and doing any form of crafting, including working in my pottery studio, is where you will find me.

If you could have dinner with anyone in the world, dead or alive, who would it be? Why? I would have dinner with my grandmother Betty while holding my grandson Jace. Grandma always had a way that made you feel at home the warmth of her love made everything better and there is always more to learn from her, including how to make the best peanut butter pie. Holding Jace while visiting with grandma would just be some bonus snuggles that are missed everyday.


What are two apps on your phone you CANNOT live without?  Google and ibotta


Any interesting facts about yourself that you’d like to share? I am always up for adventure. My mother has a very daring bucket list and I am her go-to person for those adventures. The latest was going on a helicopter ride during our vacation this year in Gatlinburg. 



Me and my mom

My contact info and territory: Julie Wheeler
Counties: Allen, Auglaize, Hardin, Mercer, Paulding, and Van Wert
Click here to find your Account Executive.

Meet our Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program Manager   

AmeriHealth Caritas Ohio’s (ACOH) pediatric preventive healthcare program is designed to improve the health of our Medicaid members from birth through age 21. By increasing adherence to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) guidelines, children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services.


Cara Skaggs, RN, BSN, CCM, is the EPSDT Program Manager for ACOH and is responsible for collaborating with multiple departments within the Plan to provide high quality support and oversight to all Medicaid-eligible individuals under age 21 who are eligible for EPSDT services. She also is an ongoing resource to you, our valued providers who are providing these most important services to our members. 


ACOH offers ongoing outreach to families to assist with gap closure as well as transportation and incentives to attend well child visits. We need your assistance identifying any issues you may be experiencing in providing these services. Please feel free to reach out to Cara for assistance Cskaggs@amerihealthcaritas.com or


Join us for Coffee and Conversations with AmeriHealth

Stop by and get to know your Account Executives and ask any questions you may have. The coffee is on us!  

November 16, Noon - 1:00 p.m.

Cool Beans Cafe

103 W. Liberty Street, Medina

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.


Population Health and Quality initiatives allow managed care plans to test potential changes for providers or members through real-world testing (i.e. gather feedback from a provider on billing documentation, collaborate on an outreach campaign to increase member compliance, etc). These are important to our patients as they allow us to keep the voice of customer at the forefront while also assisting with improving their health and wellness.

November is American Diabetes Month


American Diabetes Month is a time to rally against the diabetes epidemic. The American Diabetes Association (ADA) is leading the charge through research, education, and advocacy. They have the tools, health tips, and food ideas needed to start learning how to live a healthier life. Visit American Diabetes Association's website for more information.

Upcoming webinars

Provider orientation with ACOH

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 or contact your local Account Executive to schedule an individual orientation.


December 19 - click to register

January 23, 2024 - click to register

February 20, 2024 - click to register

March 19, 2024 - click to register


Register now for Provider Network Management module refresher training

Ohio Department of Medicaid, in partnership with Maximus, the Provider Network Management (PNM) module vendor, is excited to share that they are continuing provider awareness and training efforts. Registration for the November 6 -16 PNM module refresher training sessions is open. Click for registration instructions and for the schedule


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 cover: improving claims matching, solving reoccurring exceptions, and getting started with EVV.

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 free educational series offered by Dexcom. 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


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. November 28 - Social & Community Context: Family Caregivers.
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