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Provider Services 1-833-644-6001 |
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Submit all medical pharmacy prior authorizations (PA) online
Our online PA request form is fast, easy, and requires no user IDs or passwords. Remember to bookmark the page for future reference.
Provider Manual
The 2024 Provider Manual is available.
Removal of PA for prenatal and high risk pregnancy services
Read the alert here.
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Navigating Interim Billing |
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We are helping providers navigate the complexities of hospital billing by providing a few tips and tricks that can help you avoid any pitfalls and ensure prompt payments. Let’s review a few basic steps to help you master the art of interim billing.
Follow billing criteria
Hospitals that are subject to the prospective payment system (DRG) should only utilize bill type 112 or 113 as defined by the National Uniform Billing Committee (NUBC). You can also find additional guidance from ODM online at https://medicaid.ohio.gov/resources-for-providers/billing.
Ensure correct alignment with Admission Dates for your bill type
When reporting the admission date, it’s imperative that the admission date for any 113 bill types should align with the admission date of the preceding 112 bill type. Aligning ensures accuracy and consistency in the billing process.
Unlike 112 bill types, 113 bill types do not require an admission date to fall within the “statement covers period” date span. This flexibility allows more leeway with the submission of bills under specific circumstances.
Ensure Interim bills meet the minimum covered days requirement
Interim bills submitted should account for a minimum of 30 covered days. Adhering to these criteria ensure compliance with billing guidelines and will offer a smoother payment process.
Include a Patient Status Code
Including the patient status code is essential for proper billing procedures. Providers typically use patient status code 30 to indicate that the patient is still within the healthcare system.
Void Interim Billing at Discharge
Providers should void interim bills via EDI transactions or through the provider portal. At the time of discharge, all interim bills should be voided before submitting the final admit-through-discharge bill (type 111) to ensure accurate payment of the final claim.
Submit a Final Admit through Discharge Bill
In this case completeness matters. The final claim (type 111) should encompass a complete billing cycle from admit through to discharge. Typically, this billing should reiterate and encompass all charges submitted on prior advanced interim bills and create a comprehensive, accurate portrayal of the patient's care.
By following these steps, providers can remain billing compliant and avoid any potential delays in payment. As always, if you have questions or need assistance, please reach out to your provider account executive.
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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.
Submitting 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.
Prior authorization lookup tool
To find out if a service needs prior authorization, click here to get started.
- Wait for the page to fully load.
- Enter a CPT or HCPCS code in the search box..
- Click Submit.
- The tool will tell you if that service needs prior authorization.
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.
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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
RSV Season and NIRSEVIMAB
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.
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When should the provider submit an Appeal vs. Dispute? |
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To assist in reducing misrouted appeals and ensure that we are handling all appeal requests timely, providers should review the 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.
Appeal: provider/ member is denied services or limit/term covered service; medically related
Dispute: under-paid/ over-paid claims
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Medical appeals must be submitted
in writing to:
Claims Processing Department
AmeriHealth Caritas Ohio
PO Box 7346
London, KY 40742
Written disputes should be mailed to:
Claim Disputes
AmeriHealth Caritas Ohio
PO Box 7346
London, KY 40742
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Medicaid’s Office of Behavioral Health Policy updates provider resources for 2024 rate increases
Ohio’s recent State Fiscal Year 2024-2025 budget included historic rate increases for Medicaid providers, including Community Behavioral Health providers. Rate increases became effective January 1, 2024, and are available in the proposed Ohio Administrative Code rule 5160-27-03 amendment.
To help providers prepare for the upcoming rate increases, the Behavioral Health Provider Manual (“BH Manual”) version 1.26 is being released with several updates, including the proposed 2024 rates. Other changes to the BH Manual include content updates and clarifications, removing outdated information, and incorporating the Opioid Treatment Program Manual.
Ohio Medicaid’s BH Coding Workbook also has been updated to include 2024 rates. Please note that the workbook includes two worksheets (tabs); one for rates currently in effect and one for the rates to be effective in 2024.
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 ODM's website.
Claim submission and adjudication FAQ is now available
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 to complete the online form.
Quick email links
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 Resources and reminders |
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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
Field: 33
Field description: Billing provider Info and phone number
Required - identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter the physical location; PO Boxes are not acceptable.
- Required fields must be completed on all claims.
- Loop ID: 2010AA
- Segment: NM103, NM104, NM105, NM107, N301, N401, N402, N403, PER04.
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
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Claims Payment Systemic Error (CPSE) report |
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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.
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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’m from Cleves, Ohio, a small village in southwest Ohio. I attended Taylor High School and the University of Cincinnati.
Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours?
I worked as a Retrieval Specialist/Liaison for Humana in Risk Adjustment/Medical Records. I really enjoyed that, and I wanted to work more with providers in provider services/engagement. When I was given the opportunity to work in Southeast Ohio, I thought it would be a great fit.
What drew you to this profession?
Going to school for Health Education, I knew I wanted to stay in the healthcare field since this is what I enjoy. I had experience with cardiac rehab and I’d been working in a gym in Evendale. I needed something new and joined Humana's clinical/UM team working discharge dates for members and performing EOB letters in Dublin. I joined their Risk Adjustment Team and worked a territory that spanned from Terre Haute, IN to Maysville, KY.
What do you like to do in your free time?
I play in
golf and sand volleyball leagues during the summer. I used to play in basketball and soccer leagues however, our local facility caught fire and is no longer up and running. My wife, Lange, and I have a 3-year-old named Lennon. We are expecting #2. Overall, we spend time trying to tire Lennon out and are preparing for our baby boy in February.
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We enjoy going to the lake and traveling and camping when we can. We have two Siberian Huskies (Maple and Hazel) who are ten years old. They demand our attention! We take tons of walks/hikes and get them out to run. I love to snow ski. If we get some snow, I’ll head to Perfect North slopes or I’ll sometimes go out west. Go Bearcats, Bengals, Reds and FCC!
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
My Grandfather was a licensed electrician and had a word-of-mouth side business as I grew up. I began working with him when I was in the 6th grade. I worked summers and it continued until about 3 years ago. My grandfather and I had a lot of on-the-job lunches, and even some dinners, in the work truck or at a local chili parlor. He
is still alive and just celebrated his 88th birthday. He had to retire due to health issues but he loved what he did.
I’d ask for another one of those work truck meals.
What are two apps on your phone you CANNOT live without?
Being in a new territory this year, GPS has been helpful in assisting me to work quickly and efficiently. It's also handy when planning road trips/travels. I use YouTube for DIY projects and cooking, and at certain times, keeping Lennon busy.
Any interesting facts about yourself that you’d like to share?
I’m hoping to Backpack through Zaleski State Forest in 2024 and get more into backpacking.
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My contact info and territory:
Counties: Ross, Vinton, Hocking, Athens, Meigs, Morgan, Washington, Noble
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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.
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.
Click here to take the one-minute survey.
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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 our 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.
January 23 - click to register
February 20 - click to register
March 19 - click to register
See all of the 2024 dates here.
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Have you completed a new provider orientation?
Don't forget to complete the attestation. Click here to get started. |
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2024 Comprehensive Primary Care (CPC) Webinar Series with ODM
ODM will virtually share program updates, resources, best practices, and more. They are scheduled on::
- Thursday, February 15
- Thursday, April 18
- Thursday, September 19
- Thursday, November 14
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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.
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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.
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National Blood Donor Month
The month of January is designated as National Blood Donor Month in the United States. Due to holiday celebrations, inclement weather, and cold and flu season, the winter months are often a time of reduced donations and an increased risk for blood shortages. National Blood Donor Month celebrates blood donors during this critical time and reminds people of the importance of donating blood.
A blood donation is truly an altruistic gift that an individual can give to others in need. In only 45-60 minutes, an eligible individual can donate one unit of blood that can be separated into four individual components that could help save multiple lives.
Help ensure that this lifesaving resource is readily available to patients during this time. Find a location to give blood and schedule your life-saving donation appointment today. |
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