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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 and easy! No user ID or password needed.
Provider Manual
The Provider Manual is available.
Annual HEDIS Quality Project FAQ
Read the alert here.
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Change Healthcare System Interruption
Change Healthcare, our electronic data interchange (EDI) clearinghouse for claims and payment cycle management, continues to address their network interruption related to a security incident. Below are updates for our systems and processes:
- Claims payments: We have resumed payments for claims submitted prior to the incident. Since Change Healthcare is still unable to accept claims submissions, providers who submitted claims during the outage may be able to resubmit them either through additional solutions once they are available or once Change Healthcare’s connectivity is restored, through Change Healthcare. We appreciate the inconvenience this is causing providers and are exploring other options for the submission of claims.
- Electronic remittance advice: Electronic remittance are available at this time. However, some individual remittance advices may not be available due to Change Healthcare’s security incident.
- Prior authorization submission and processing: The prior authorization systems continue to operate normally.
- Eligibility verification, claim status inquiry, and authorization inquiry: These capabilities continue to be available via NaviNet. If you do not have access to NaviNet provider portal, please sign up.
Please note, in the interim, our Provider Services Department will not be able to assist with processing of your payments any sooner. If you have other questions, you may contact Provider Services at 1-833-644-6001.
We thank you for your partnership and will continue to provide updates as we work to resolve the downstream impacts of Change Healthcare’s service interruption. |
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 Ohio Department of Medicaid updates |
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Medicaid Agreement Revalidations
IMPORTANT UPDATE: Terminations resumed effective January 23, 2024, for failure to complete Medicaid Agreement Revalidations in the Provider Network Management module.
If you receive a revalidation notice, 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 started terminating providers who fail to complete their revalidation prior to their specified deadline. To complete revalidation, please visit PNM & Centralized Credentialing.
Vaccines for Children program
Effective April 30, the Vaccines for Children program will no longer require the use of the SL modifier to indicate when a provider is participating in the program for claims for reimbursement.
Please see the below updated billing guidelines:
AmeriHealth Caritas Ohio PCPs 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 (VFC) 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:
- Toxoid/Immunization CPT codes must be submitted with a charge amount greater than zero.
- Providers will receive reimbursement for the administration of the vaccine only.
Review and update your Specialties page in the Provider Network Management module when completing revalidation or reapplication
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?
Reminder to providers regarding urine drug screening
Drug screen testing detects the presence of drugs or drug classes in a patient’s system during an encounter. The results are reported as positive or negative for the presence of a drug or drugs but do not indicate specific levels. The tests provide information about recent drug use but do not distinguish between occasional users and those who are dependent on or otherwise impaired by drug use.
Drug screen testing includes:
- Presumptive drug class screening used to identify possible use or non-use of a drug or drug class. It is done on a random basis or for cause, the latter of which should be documented in the medical record. In substance use disorder treatment settings, presumptive testing should be a routine part of initial and ongoing patient assessment.
- Definitive drug class screening comprised of qualitative (drug is present or absent), semi-quantitative, or quantitative (measured) tests to identify possible use or non-use of a specific drug; typically, therapeutic drug assay procedures are quantitative tests. Definitive testing may be used to detect specific substances not identified by presumptive methods and to refine the accuracy of the test results when the results are needed to inform clinical decisions.
Drug testing should supplement information obtained by history and physical examination and should never be the sole basis for making a diagnosis of a substance use disorder (American Society of Addiction Medicine, 2019). Drug testing should be performed for individuals who would be helped most by such screens. Routine drug screening in the absence of clear clinical suspicion for illicit use should be avoided. Choice of test matrix, selection, and frequency should fit the needs of the tested population, with more intense and less predictable testing reserved for persons at highest risk of drug use (American Society of Addiction Medicine 2019, Manchikanti, 2012).
AmeriHealth follows OAC rules associated with presumptive and definitive drug screens.
- For presumptive screens, thirty dates of service per benefit year; and
- For definitive tests, twelve dates of service per benefit year.
PNM portal
Until it is fully active, please continue to send roster updates to both PNM and the MCO’s. Behavioral Health providers ARE able to only update through the PNM portal without submitting rosters to the MCO’s.
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. |
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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.
Correcting Claims
Oops! What if I submitted claims with the wrong rate or CPT code? Please refer to our Provider Claims and Billing Manual on how to submit corrected claims on page 52.
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? |
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Item and Definitions
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Timeframe
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Contact Information
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Appeal
Filed by the member or provider on behalf of the member (with a waiver), related to a denied Service/IP service (Prior Auth denials, Limit to service/Auth) when there is no claim on file.
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60 days from the date of denial letter sent by UM.
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Medical appeals must be submitted in writing to:
Claim Processing Department
AmeriHealth Caritas Ohio
P.O. Box 7346
London, KY 40742
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Inquiry
Provider asking for more information on a claim and how it was processed.
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None
If determined the claim can be adjusted, then the inquiry is a dispute and should follow that timeframe.
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NaviNet portal (www.navinet.net)
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Dispute (or Provider Claim Appeal)
Provider disagreeing with the way a claim was processed, paid, or denied.
ODM outlines the following categories of items that are considered a dispute:
- Claim Status
- Eligibility
- Other insurance
- Improper claim submission
- Overpaid/underpaid
- Provider not eligible to provide service
- Payment amount clarification
- Provider not credentialed
- Duplicate claim
- Timely filing
- Documentation issues
- Recoupments
- Prior Authorization
- Medical Necessity
- Level of Care (LOC)
- Non-covered services
- Provider affiliation
- Payment not received
- Patient Liability
- Sterilization/Hysterectomy consent form
- Past Dispute Timeframe
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12 months from the DOS or 60 days from the EOB date.
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Written disputes should be mailed to:
Claims Disputes
AmeriHealth Caritas Ohio
P.O. Box 7126
London, KY 40742
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Access the Provider Dispute Submission Form (PDF) |
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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 am from Cleveland where I attended Cleveland Heights High School and Brush High School. I moved to Toledo for college to attend the University of Toledo (Go Rockets)! I earned a BS degree in Exercise Science and my Master's Degree in Public Health.
Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours?
When I learned a new managed care plan was being implemented in Ohio I was immediately intrigued by the mission and history of the organization. I also discovered a few people I knew worked for AmeriHealth Caritas and raved about the company’s culture and vision. It has truly been an honor to be part of an organization and team dedicated to making a tangible difference in the way Medicaid is being delivered in Ohio.
What drew you to this profession?
My professional journey has been driven by a deep commitment to advocate for those that are underrepresented and underserved. My entire career in healthcare has been serving those who are frequently overlooked, and I find great joy in facilitating access to high quality care for our members.
What do you like to do in your free time?
I find joy in spending time with my husband and kids, staying active through workouts and walking/rucking, reflecting through journaling, unwinding watching TV shows and movies, and managing budgets.
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If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
I would love to have dinner with my paternal great-grandmother who passed away when I was 12 years old. She was a remarkable woman whose wisdom and presence left a lasting impression on me. Sitting across from her at the dinner table, I would eagerly listen to her stories, savoring every nugget of insight she had to offer. She was a dynamic woman who didn’t have much financially, but possessed an abundance of wisdom, love, and an unwavering faith in Jesus.
What are two apps on your phone you CANNOT live without?
I can’t live without Marco Polo (to stay in touch with friends and family) or WAZE (for navigation
Any interesting facts about yourself that you’d like to share?
I served as a Precinct Election official (PEO) for the last 11 elections including primary, general, and special elections. It fills my bucket to ensure fair and smooth voting processes for my community.
 Kristal with her family on a Carnival Cruise to the Bahamas and Bimini in February. Everyone pictured has a name that starts with either a C or a K.
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My contact info:
Kristal Barham, Manager Provider Services
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 Upcoming webinars |
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Check out this CEU opportunity from AmeriHealth Caritas Ohio!
Our Market Health Equity Program Director, Patricia Lyons Ph.D., LISW-S will present a virtual workshop on April 25: Socially and Culturally Responsive Evidence-based Care. More details coming to our website.
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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 on these dates or contact your local Account Executive to schedule an individual orientation.
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March 19 - click to register
April 23 - 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 if you have already attended a session. 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. The sessions cover: improving claims matching, solving reoccurring exceptions, and getting started with EVV.
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National Colorectal Cancer Awareness Month
Colorectal cancer screening saves lives. Colorectal cancer is the second deadliest cancer in the United States. Yet it's one of the few cancers that's preventable thanks to screening. Here are two reasons why getting checked matters:
- Screening can find the warning signs of colon and rectal cancer, letting doctors take action to prevent the disease
- Screening can also find colorectal cancer early, when treatment is most effective.
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