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Provider Manual
AmeriHealth Caritas Ohio will be updating its provider manual for 2024. To see all changes that will be effective January 1, 2024, click here and refer to the highlighted sections.
Dental Benefit Update
Effective January 1, 2024, AmeriHealth Caritas Ohio will be covering the following benefits in addition to the existing Medicaid package for their adult subgroups.
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ADA Code
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Code Description
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Fees
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D1208
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Topical application of fluoride - excluding varnish
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TBD
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D4346
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Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation
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TBD
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D5221
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Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)
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TBD
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D5222
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Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)
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TBD
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D5223
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Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
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TBD
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D5224
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Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)
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TBD
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D5225
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Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth)
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TBD
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D5226
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Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)
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TBD
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D7321
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Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
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TBD
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Detailed information regarding filing criteria, benefit limitations, and clinical guidelines is available in our Office Reference Manual at https://www.dentaquest.com/en/providers. For further questions, please contact your local Provider Engagement Representative at DL-ProviderRelationsOH@greatdentalplans.com.We appreciate your dedication to serving AmeriHealth Caritas Ohio members and look forward to continuing to work with you to make Ohio smile! |
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Did you receive the 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 anonymous feedback to let us know how we are doing and where we need to improve. Thank you in advance for taking the time to participate.
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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.
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Removal of prior authorization for prenatal and high risk pregnancy services
Beginning Dec. 22, 2023, prior authorization for the Healthcare Common Procedure Coding System (HCPCS) codes and services listed in the table below do not require prior authorization:
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H1000
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Prenatal care: at risk assessment
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H1000 33*
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Web-based Pregnancy Risk Assessment form (PRAf) submission
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H1001
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Prenatal care: antepartum management
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H1002
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Prenatal care: care coordination
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H1003
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Prenatal care: individual education
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H1005 TH*
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Prenatal care enhanced srv pk
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H1010
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Nonmed family planning education
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*Modifier 33 = Preventive Services
*Modifier TH = Obstetrical treatment/services; prenatal or postpartum
Removal of the prior authorization and medical necessity review for these services is part of AmeriHealth Caritas Ohio’s continued dedication to supporting providers in our shared commitment to high quality health care for our members. As a reminder, when you do need to verify whether a service requires prior authorization, use the Prior Authorization Lookup Tool on the provider website at:
https://www.amerihealthcaritasoh.com/provider/resources/prior-auth-lookup-tool.aspx.
Questions? Please contact your Provider Account Executive or Provider Services at 1-833-644-6001.
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Navigating Interim Billing
This month 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 patients 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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Transportation benefits
AmeriHealth Caritas Ohio offers transportation benefits for members. We cover rides to medically necessary emergency and non-emergency care visits. We will make sure our members have the kind of ride they need.
To set up a ride
Call MTM - our ride vendor - at 1-833-664-6368 or call Member Services at 1-833-764-7700 (TTY 1-833-889-6446).
- Set up the ride at least 48 hours before the healthcare visit. ͞This does not apply for urgent member needs (like same-day or next-day visits) and hospital discharges.
- Have the full address of the location for the visit.
- The member should let the driver know:
- How to contact them
- If there is a certain entrance to use
- If they will be bringing anything like a wheelchair, something to help with walking, or a child’s car seat. (If using a car seat, they must provide the seat and be able to set up and remove it.)
To cancel or reschedule a trip
Call MTM at 1-833-664-6368 or call Member Services at 1-833-764-7700 (TTY 1-833-889-6446) at least 24 hours before the visit.
To file a complaint
Call Member Services at 1-833-764-7700 (TTY 1-833-889-6446).
For trips longer than 30 miles
If travel is 30 miles or more from the member's home to get covered healthcare services, AmeriHealth Caritas Ohio will cover the rides to and from the provider’s office. Call MTM at 1-833-664-6368 at least 48 hours before the trip or call Member Services at 1-833-764-7700 (TTY 1-833-889-6446)
For trips less than 30 miles
Rides are available for certain services through the local County Department of Job and Family Services (CDJFS) Non-Emergency Transportation (NET) program.
Contact your County Department of Job and Family Services for questions or help with NET services.
AmeriHealth Caritas Ohio provides a supplemental transportation benefit that covers up to 60 one-way trips per member per year for provider visits less than 30 miles away.
Full benefits can be found here.
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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
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?
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.
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:
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Claims Processing Department
AmeriHealth Caritas Ohio
PO Box 7346
London, KY 40742
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Written disputes should be mailed to:
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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
To help providers prepare for the upcoming rate increases, the Behavioral Health Provider Manual (“BH Manual”) version 1.26 was 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.
Read the entire bulletin here.
Important: Provider Network Management incomplete affiliation steps may impact provider billing
Through a series of Provider Network Management (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.ODM has identified that providers tend to leave affiliations in one of two incomplete statuses:
- Pending Approval.
- Confirmed.
A provider affiliation can be initiated and completed by the group/organization/hospital, or it can be initiated through the rendering practitioner. If the affiliation is initiated through the rendering individual, it is not complete and remains in a “Pending Approval” status until the group/organization/hospital accepts and saves the affiliation. At that point it will appear “Confirmed.” For the provider affiliation to be sent downstream and receive an “Active” status, there are two remaining critical steps:
- Click “Save” at the top of the page to save all the updates. Once saved, the user will have a new “Submit for Review” button appear.
- Click “Submit for Review.” Users must click on this button to complete the process and submit the affiliations downstream. Affiliations are fully executed only once this final step has been taken.
If these steps are not completed, the provider affiliation is not sent downstream, and providers will experience claims payment issues.
For more information, the PNM Learning tab includes step-by-step instructions in three quick reference guides:
Adding a Hospital Affiliation
Adding an Individual Provider to a Group-Organization
Affiliations
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
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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
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
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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 am from Akron, OH where I attended Springfield High School. I went on to Study Biological Sciences at Ohio University, where I graduated in 2002.
Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours?
I saw the opportunity of launching a new market aligned with a company with a heart.
What drew you to this profession?
The opportunity to assist our members with having better access to healthcare is a rewarding profession. I am happy to be a part of this.
What do you like to do in your free time?
I enjoy spending time with my |
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family and friends most of all. After this, enjoying a cigar with a cup of coffee at the end of the day brings me rest and joy.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
My dad. I miss him dearly.
What are two apps on your phone you CANNOT live without?
Snapchat (for communication with my kids), and Audible because I am always listening to books.
Any interesting facts about yourself that you’d like to share?
My name does not have periods, because it doesn’t stand for anything. I am AZ III, and my middle son is AZ IV.
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My contact info and territory: AZ Patterson
Counties: Cuyahoga, Summit, and Portage Counties
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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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December is National Influenza Awareness Month
Flu is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs. It can cause mild to severe illness, and at times can lead to death. The best way to prevent flu is by getting a flu vaccine each year.
Get the facts
- People with influenza can spread it to others up to about 6 feet away.
- People with the flu are most contagious in the first three to four days after their illness begins.
- The flu is different from a cold. Unlike a cold, it usually comes on suddenly.
- Flu viruses are spread mainly by tiny droplets made when infected people cough, sneeze or talk.
People at higher risk from flu
Some people are at higher risk of developing serious flu-related complications if they get sick. This includes:
- People 65 years and older
- People of any age with certain chronic medical conditions (such as asthma, diabetes, or heart disease)
- Pregnant people
- Children younger than 5 years
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Common signs & symptoms of flu
Flu symptoms usually come on suddenly. People who have the flu often feel some or all of these symptoms:
- fever* or feeling feverish/chills
- cough
- sore throat
- runny or stuffy nose
- muscle or body aches
- headaches
- fatigue (tiredness)
- some people may have vomiting and diarrhea, though this is more common in children than adults.
*It’s important to note that not everyone with flu will have a fever.
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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.
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December 19 - click to register
January 23, 2024 - click to register
February 20, 2024 - click to register
March 19, 2024 - click to register
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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.
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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