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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 Provider Manual is available here.
Annual HEDIS Quality Project FAQ
Read the alert here.
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AmeriHealth Caritas Ohio - one year of building healthy Ohio communities! |
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We marked our one-year anniversary with an event at our Dublin headquarters to thank the community organizations and others who have played a pivotal role in our successful launch. State Senator Stephanie Kunze and State Representative Anita Somani, M.D. both commended AmeriHealth Caritas Ohio’s outstanding work done for their constituents and the residents of Ohio, with Sen. Kunze presenting her commendation in person during the event.
AmeriHealth Caritas Ohio is helping build a stronger Medicaid program for Ohioans who need it through the state’s Next Generation of Medicaid Managed Care (NextGen).
Looking ahead, AmeriHealth Caritas Ohio remains dedicated to our mission of providing innovative health solutions and fostering partnerships that make a |
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positive impact on members’ lives through innovative solutions such as the AmeriHealth Caritas Mobile Wellness and Opportunity Center, peer-to-peer support, and digital outreach and education platforms.
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 Ohio Department of Medicaid updates |
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IMPORTANT UPDATE: Terminations resumed January 23, for failure to complete Medicaid Agreement Revalidations in the Provider Network Management module
If you are currently due for a revalidation in the Provider Network Management (PNM) module, it is imperative that you take immediate action to complete and submit your revalidation application to renew your Ohio Medicaid Provider Agreement. On January 23, Ohio Department of Medicaid (ODM) started terminating providers who failed to complete their revalidation prior to their specified deadline.
ODM resumed provider revalidation notices in June 2023 as part of the federally required unwinding process from the COVID public health emergency. ODM issues a series of notices with the first one delivered 120 days prior to your Medicaid agreement end date. Subsequent reminders are issued at 90 days, 60 days, and a final notice at 30 days. If you receive a revalidation notice, it is imperative that you take action to complete your revalidation on time. All providers are subject to either three- or five-year time-limited provider agreements.
To find out if you are due for revalidation and additional information, click here.
Reminder: review and update your Specialties page in the Provider Network Management module when completing revalidation or reapplication
ODM resumed provider revalidations on October 1, 2023. Since then, ODM has seen an increase of provider specialty discrepancies, especially among the Physician/Osteopath Individual provider type. Because of this, providers are strongly encouraged to review the provider specialty page in the Provider Network Management (PNM) module for accuracy.
What action do providers need to take?
Review the PNM Specialties page during your revalidation/reenrollment process to make any updates or adjustments to the active practicing specialties. Please note, the “200 Physician/Osteopath Individual” specialty type is no longer a valid specialty and would require an update to add the correct specialty in PNM. See the Specialty Quick Reference Guide for instructions.
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.
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 administrator change form
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
Email links
EPSDT-HEALTHCHEK annual education as required by ODM
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides comprehensive and preventative health care services for children under age 21 who are enrolled in Medicaid. EPSDT is key to ensuring that children and adolescents receive appropriate preventative, dental, mental health, developmental, AND specialty services.
Screenings Must Include:
- Comprehensive Health and Developmental History
- Comprehensive Unclothed Physical Exam
- Laboratory Tests – Including Lead Toxicity Screening as guided by the child’s age
- Appropriate and needed immunizations
- Health Education – Anticipatory Guidance including Child Development, Healthy Lifestyles, and Accident and Disease Prevention
- Vision Services – at minimum, diagnosis and treatment for defects in vision, including eyeglasses
- Dental Services – at minimum, relief of pain and infections, restoration of teeth, and maintenance of dental health
- Hearing Services – at minimum, diagnosis and treatment for defects in hearing, including hearing aids
- Nutrition assessment and education
- Other Necessary Health Care Services – diagnostic and treatment services must be provided when a screening examination indicates the need for further evaluation
Important Links and Information
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 Resources and reminders |
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Need help?
Prior authorizations
Submit authorizations electronically through NaviNet
AmeriHealth Caritas Ohio offers our providers access to our Medical Authorizations portal for electronic authorization inquiries and submission. The portal is accessed through NaviNet and located on the Workflows menu.
In addition to submitting and inquiring on existing authorizations, you will also be able to:
- Verify if No Authorization is Required
- Receive Auto Approvals, in some circumstances
- Submit Amended Authorization
- Attach supplemental documentation
- Sign up for in-app status change notifications directly from the health plan
- Access a multi-payer Authorization log
- Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities (fax is no longer required)
- Review inpatient admission notifications and provide supporting clinical documentation
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 at the bottom of the page
- Click Submit
- The tool will tell you if that service needs prior authorization
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 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.
Member Rights and Responsibilities
AmeriHealth Caritas Ohio complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, ethnicity, national origin, age, disability, sex, pregnancy, religion, National Guard or Veteran’s status, sexual orientation, and gender identity or expression or any other status protected by federal or state law. AmeriHealth Caritas Ohio is committed to complying with all applicable requirements under federal and state law and regulations pertaining to member privacy and confidentiality rights. AmeriHealth Caritas Ohio has provided its members with this information on their rights. We look forward to providers support in further protecting these rights. These can also be found in the member handbook. |
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 Claims and billing |
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Consent Forms
Providers must submit the appropriate required forms (ODM 03197, ODM 03199, HHS-687, and HHS687-1 [SPANISH VERSION]) with the claim’s submission for these services. Appropriate consent forms can be found on AmeriHealth Caritas Ohio's website or on the ODM website at Pregnancy Risk Assessment | Medicaid (ohio.gov). Providers can submit the consent form along with their claim through Change Healthcare:
- Submit a 275 claim attachment transaction. AmeriHealth Caritas Ohio is accepting ANSI 5010 ASC X12 275 unsolicited attachments via Change Healthcare. Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 attachment submissions via payer ID 35374.
There are three ways that 275 attachments can be submitted:
- Batch - you may either connect to Change Healthcare directly or submit via your EDI clearinghouse.
- API via JSON - you may submit an attachment for a single claim.
- Portal - individual providers can register at Change Healthcare to submit attachments.
The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, xml, doc, and txt. View the Change Healthcare 275 claims attachment transaction video for detailed instructions on this process. In addition, the following 275 claims attachment report codes have been added. When submitting an attachment, use the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the Claims Filing Instructions (PDF).
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Attachment type
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Claim assignment attachment report code
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Itemized bill
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03
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Medical records for HAC review
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M1
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Single case agreement (SCA)/LOA
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04
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Advance beneficiary notice (ABN)
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05
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Consent form
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CK
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Manufacturer suggested retail price/invoice
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06
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Electric breast pump request form
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07
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CME checklist consent forms (child medical eval)
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08
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EOBs — for 275 attachments, should only be used for non-covered or exhausted benefit letter
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EB
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Certification of the Decision to Terminate Pregnancy
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CT
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Ambulance trip notes/run sheet
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AM
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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.
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 claim
- Loop ID: 2010AA
- Segment: NM103, NM104, NM105, NM107, N301, N401, N402, N403, PER04.
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 you 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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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, 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.
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Appeal: provider/ member is denied services or limit/term covered service; medically related
Dispute: under-paid/ over-paid claims
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 7126
London, KY 40742 |
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Access the Provider Dispute Submission Form (PDF)
Billing for Hospital Readmission
For prompt and accurate payment processing, please consult ODM's Hospital Guidance on Hospital Readmissions found on page 31 of the Hospital Billing Guidelines.
Please note, that ODM instructs the following concerning readmissions to a hospital:
- If a recipient is an inpatient in a hospital, is discharged, then subsequently re-admitted to the same hospital within a day, the hospital must collapse the two inpatient stays into one admit through discharge claim. The hospital must report one non-covered day at the header and use Revenue Code 180 to report a non-covered day at the detail.
- For example, if the recipient is hospitalized 1/1 and is discharged to a NF on 1/5, then re-admitted to the hospital on 1/6, the hospital must report one non-covered day for the first date of discharge (1/5) at the header, and one non-covered day at the detail level, RCC 180.
Depending on which claim (hospital or NF) is paid first, the second claim will deny as a duplicate due to a systems configuration limitation that will not process two claims with overlapping dates of service (i.e., the day the patient is readmitted to the NF for 8 hours or more). As a workaround, if your claim is denied as a duplicate, please resubmit your claim via the 6653 process for manual review.
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Mobile Wellness, meeting communities right where they are
Our Mobile Wellness and Opportunity Center can come to your community! Depending on availability and established criteria, you can work with AmeriHealth Caritas Ohio to
conduct classes, wellness events, or health education within and around the bus.
The mobile unit is equipped with kiosks where attendees can access computers and a private location where providers can perform health screenings and engage personally with members.
Working with AmeriHealth Caritas Ohio, you can increase accessibility to services that address the social determinants of life and improve conditions for members of the community. We are pleased to offer this convenience at no cost to you and your community.
For more information or to reserve time with the Mobile Wellness and Opportunity Center, click to complete the request form or email us at Comms@AmeriHealthCaritasOH.com. We welcome the chance to work with you to help people get care, stay well, and build healthy communities. |
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Tell us a little bit about where you’re from.
I was born and raised in Lima, Ohio and attended Shawnee High School/Sinclair Community College.
Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours?
My passion has always been service to others, and I get a great bit of joy being able to help others solve problems. I worked for another health plan for the past 12 years, and when I learned about AmeriHealth, their mission, and that they were going to come into Ohio, I jumped at the chance to be part of it. One of the things that really stood out to me is the name AmeriHealth Caritas. Caritas in Latin means “love” or “charity”, which I think is just so fitting for the work we do.
What drew you to this profession?
Being able to make a difference for the underserved, but also being able to support a team of people in that work.
What do you like to do in your free time?
I have many hobbies. I love to crochet/knit, roller skate, swim, play piano, doing anything that involves
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being outdoors and spending as much time as possible with my grandchildren!
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
My grandparents who raised me just because I miss them and would love for them to meet my grandchildren.
What are two apps on your phone you CANNOT live without?
Signal, because it keeps me connected to my whole family, and Google.
Any interesting facts about yourself that you’d like to share?
I have 3 children, 7 grandchildren, and I used to do artistic competitive roller skating!
My grandchildren - my world!
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My contact info:
Trudy Huffman, Manager Provider Services
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 Upcoming webinars |
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Introduction to Acceptance and Commitment Therapy (ACT)
Research shows that to be psychologically and emotionally healthy, we need to learn how to feel our emotions fully – even the painful ones. Instead of trying to control or avoid how we feel, it’s important to learn how to approach our emotions with openness and flexibility, while continuing to pursue our personal values and life goals. Acceptance and Commitment Therapy (ACT) is an evidence-based approach that teaches us how to do just that.
3 FREE CEU's have been approved for Counselors and Social Workers
This virtual workshop will be presented by our Behavioral Health Medical Director, Dr. Laurie Greco, Ph.D.
Friday, February 23, 9:00 a.m. – 12:15 p.m.
Get all of the details here
Click here to register for the Zoom Webinar
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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.
February 20 - click to register
March 19 - click to register
See all the 2024 dates here.
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Have you completed a new provider orientation?  |
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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, 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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American Heart Month
You have the power to take action to protect yourself against heart disease. Small heart-healthy actions like adding more movement to your day or choosing healthy foods, can have a big impact on protecting #OurHearts.Learn more about the causes of heart disease and what individual risk factors with this fact sheet: Heart Smart Basics guide: What to Know to Keep Yours Healthy.
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Black History Month
February is black history month and AmeriHealth Caritas Ohio wants to take the opportunity to recognize some of the factors that affect this pillar of our community.
The inventor of the traffic light, Garret Morgan, was a community leader and inventor who was renowned for his ingenuity. Morgan would serve as an important leader in the black community. He co-founded the Cleveland Association of
Colored Men, which would later be merged with the NAACP. Morgan’s efforts, like the Traffic light continue to foster growth and development of our communities. This is an effort we strive for though a number of the programs we offer to support our member’s communities.
We are celebrating Black History Month by sharing some of the measures AmeriHealth Caritas Ohio is using to help serve this community. Due to a combination of socio-economic and clinical factors, Black infants are 2.6 times more likely to die before their first birthday than white infants in Ohio.
Among the factors the Ohio Department of Health lists as most influential to infant mortality, they often happen outside of a hospital or clinic. like transportation and education. The presence of these help to ensure parents and children can live healthy lives.
Our Bright Start program is designed to support our pregnant members and enhance the care that they receive. Our Bright Start team is a one-stop resource for education, care coordination, connection to community-based organizations, and information needed for a healthy pregnancy and baby. More information about Bright Start, as well as a number of other benefits we provide to help support our members, is available on our website. |
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