June 2024
Provider Services 1-833-644-6001 

Change Healthcare Access Issue

AmeriHealth Caritas Ohio has not established a timeline for reconnecting to Change Healthcare Electronic Data Interchange (EDI) transaction systems. We are working diligently to assess when to restore the connection for EDI transactions. Our decision-making process will include receiving third-party assurance regarding the security of Change Healthcare systems, as well as internal security validation.
 
We are aware that some providers are experiencing difficulty with reconciliation of accounts due to some detailed payment recovery information missing from the provider remittance advice. Due to the Change Healthcare security incident, remittance advices generated after February 21, do not include certain claim recovery information that was previously provided. We are collaborating with Change Healthcare on a solution for this issue. We are confident as Change Healthcare continues to restore services; this information will soon become available.
 
As a reminder, providers can view and download an electronic remittance PDF via the NaviNet provider portal. Providers can also access the ERA/835 file through ECHO Health’s provider payment portal at: www.providerpayments.com/Login.aspx. If you are not currently registered with ECHO for access to the portal, you will have to create a new account. 
 
Questions: Please note, in the interim, our Provider Services Department will not be able to assist with processing of your payments or access to remittance advice any sooner. If you have other questions, you may contact Provider Services at 1-833-644-6001
 
We appreciate your partnership and patience as we work to re-establish services and will continue to share additional information as it becomes available. 

  Ohio Department of Medicaid updates
UPDATED state fiscal year-end claims submission and provider payments 
What providers need to know about Medicaid claims submitted as the State of Ohio finalizes payments for State Fiscal Year 2023 ending June 30.
 

Claims submitted after 12 p.m. on Friday, June 23, will be held for processing until the Ohio Administrative Knowledge System (OAKS), the state's accounting system, is up and running for state fiscal year (SFY) 2024 (beginning July 1). Ohio Department of Medicaid (ODM) anticipates issuing final provider payments for SFY 2023 on Wednesday, June 28, however, fiscal year-end processing may cause a delay in payment until OAKS is up and running for SFY 2024. ODM anticipates issuing the first payment of SFY 2024 to providers on July 7. Please note, as a result of fiscal year-end processing and the July 4th holiday, OAKS processing may experience a brief delay and payment may not be made until the week of July 10.


July 1 Electronic Visit Verification program changes 
ODM is making policy updates and system enhancements to the Electronic Visit Verification (EVV) program. These changes go into effect July 1, and include: 
  • Ohio Medicaid EVV proposed rule updates.
  • System enhancements to Sandata devices and applications.
Requirements for the current EVV program are detailed in Ohio Administrative Code (OAC) rule 5160-1-40. Ohio Medicaid is proposing to separate this comprehensive rule into four focused rules: 
  • OAC 5160-32-01 EVV program.
  • OAC 5160-32-02 EVV data collection.
  • OAC 5160-32-03 Alternate EVV vendor.
  • OAC 5160-32-04 EVV program provider requirements.
To stay updated on OAC rule activity, please create an account here. To view previous, current, and proposed OAC rule update activity, visit the Register of Ohio website here.

Materials and educational opportunities will continue to be communicated as the program prepares for changes occurring July 1. To stay updated on ODM EVV program communications you can sign up for notifications by clicking on the ODM website.

 

ODM authorizing $10 million to help at-risk youth across Ohio

ODM, in partnership with the State of Ohio’s Child and Adolescent Behavioral Health Center of Excellence at Case Western Reserve University, is helping to launch and expand access to a critical mental health service in 59 counties, which results in a total of 76 out of the 88 counties in Ohio having access to an Intensive Home-Based Treatment program. ODM authorized $10 million to support a much-needed mental health service called Intensive Home-Based Treatment (IHBT). Read the entire press release

 

Reimbursement information

In 2023 ODM collected responses from all the MCEs regarding the claims and prior authorization denials processes. To streamline this for providers, ODM created two grids, one for claims denials and one for PA denials. The intent of both grids is for providers to have tools that explain the MCE claims and PA denials processes within one location. Both grids are located here: Reimbursement Information.

 
Medicaid agreement revalidations
IMPORTANT UPDATE: Terminations resumed effective January 23, 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.
 

The importance of the SL modifier in childhood vaccines (corrected article)

Vaccines for Children (VFC) 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 updated billing guidelines below:

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.
 
Updated rates
The new rates are available on ODM's website.
 
Update your specialties page in the Provider Network Management module 
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 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 requires 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 for care delivered in 2024.
 
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, 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 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 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 
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. You can review the FAQ on the submitting claims and prior authorizations page on the Next Generation website.
 

EPSDT- HEALTHCHEK annual education as required by ODM

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides comprehensive and preventative healthcare 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

Email links

 Resources and reminders

Need help?

Reminder to providers regarding overpayments

AmeriHealth's Claims Cost Containment Unit is responsible for the manual review of overpaid claims submitted by the Program Integrity department for potential recovery. Claims submitted to the Claims Cost Containment Unit for review are outside of the Subrogation and Check Reconciliation areas. Some examples of identified waste include:

  • Incorrect billing from providers causing overpayment
  • Overpayment due to incorrect set-up or update of contract/fee schedules in the system
  • Overpayments due to claims paid based upon conflicting authorizations or duplicate payments
  • Overpayments resulting from incorrect revenue/ procedure codes, retro TPL/Eligibility

The Claims Cost Containment Unit is also responsible for the manual review of provider-initiated overpayments. Providers who self-identify claim overpayments may submit their inquiries for review to:

AmeriHealth Caritas Ohio

Attn: Claims Cost Containment

PO Box 7320

London, KY 40742

 

Further information can be found on pages 115 through 117 of the AmeriHealth Caritas Ohio Provider Manual.

 

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 33 of the AmeriHealth Caritas Ohio Provider Manual.  
  Claims and billing
How to investigate a claim
  1. Log into NaviNet.
  2. On the Health Plans menu, under My Plans, click AmeriHealth Caritas Ohio.
  3. Under Workflows for This Plan, click Claim Status Inquiry, and then find your claim.
  4. On the Claim Details screen, above the status bar, click Claim Investigation. The Investigation Claim # pop-up window appears.
  5. Choose an investigation type, and then type your comments for the investigation reviewers. Claim investigations are per claim, not per line item. To reference a specific claim line, provide the line number in the Comments box.
  6. In the remaining boxes, type your contact information for this investigation so that customer service can contact you, if necessary.
  7. Click Submit.
A confirmation message appears. For example:
Your Investigation Request for Claim # 118833994 has been submitted to the plan.
Our goal is to respond to your inquiry within 7 days, however, at times due to volumes of complexity our response may take up to 30 days.

To check the status of your investigation after you submit it, click Claim Investigation Inquiry under Workflows for This Plan.

If you submit an investigation without required information, AmeriHealth Caritas Ohio cannot complete it. AmeriHealth Caritas Ohio responds to the investigation and notes the missing information. Click here for the NantHealth Help Center.

 

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).
 

Attachment type

Claim assignment attachment report code

Itemized bill

03

Medical records for HAC review

M1

Single case agreement (SCA)/LOA

04

Advance beneficiary notice (ABN)

05

Consent form

CK

Manufacturer suggested retail price/invoice

06

Electric breast pump request form

07

CME checklist consent forms (child medical eval)

08

EOBs — for 275 attachments, should only be used for non-covered or exhausted benefit letter

EB

Certification of the Decision to Terminate Pregnancy

CT

Ambulance trip notes/run sheet

AM

 
No paper claims
The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). Use AmeriHealth Caritas Ohio’s EDI Payer ID# 35374. 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.
See page 17 of the Provider Claims and Billing Manual.  
 

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.

 

When should the provider submit an Appeal vs. Dispute?

Item and Definitions

Timeframe

Contact Information

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.

60 days from the date of denial letter sent by UM.

Medical appeals may be submitted via:

 

Mail: AmeriHealth Caritas Ohio

Attn: Member Appeals Coordinator 

PO Box 7346

London, KY 40742

 

Phone: AmeriHealth Caritas Ohio Member Services

1-833-764-7700

(TTY: 1-833-889-6446)

 

Secure contact formhttps://apps.amerihealthcaritasoh.com/securecontact/index.aspx

Inquiry

Provider asking for more information on a claim and how it was processed.

None

If determined the claim can be adjusted, then the inquiry is a dispute and should follow that timeframe.

NaviNet portal (www.navinet.net)

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 

    12 months from the DOS or 60 days from the EOB date.

    Disputes may be submitted via:

    Phone: 1-833-644-6001 (Select the prompts for the correct department and then select the prompt for claim issues).


    NaviNet portal: https://navinet.secure.force.com/ with the claims adjustment inquiry function. 


    Mail: The request must include a copy of the dispute resolution letter.

    AmeriHealth Caritas Ohio

    Attn: Provider Claim Inquiry Team

    PO Box 7126

    London, KY 40742 


    Fax: 1-833-216-2272 

     

     

     

    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.

    Diabetes self-management education enhanced reimbursement rates 

    AmeriHealth Caritas Ohio and the Ohio Managed Care Organizations (MCOs) are working collaboratively to make diabetes management easier for providers and their patients. Diabetes education and support for the use of continuous glucose monitors (CGMs) have proven to be effective in diabetes care management.
    To facilitate increased utilization of these enhanced tools, AmeriHealth Caritas Ohio and the other MCOs will pay an enhanced rate to providers rendering Diabetes Self-Management Education (DSME) and billing the appropriate codes: G0108 and G0109. In addition, PA is not required for members who receive a covered CGM device through durable medical equipment (DME) providers or through their pharmacy. Providers must use HCPCS codes A4239 and E2103 for CGMs provided through DME.

                 

    Services rendered in 2023 should be submitted without delay to prevent denials.

    For additional information regarding these updates, including who to contact at each MCO for questions, see the quick reference guide on our provider website.

    Pain Self-Management Education (PSME) is in full swing!  

    PSME is a four-session educational program for adults living with chronic non-cancer pain. PSME teaches pain self-management, healthy lifestyle, mindfulness, and healthy coping skills, with the goal of empowering people to live full and productive lives with pain.

     

    This program is offered in collaboration with Meridian HealthCare at no cost to adults 18+ living with chronic pain and insured by ANY Ohio Medicaid plan.

     

    To refer to this program, please direct patients to contact Meridian HealthCare directly at 1-330-797-0070 or email chronicpain@meridianhealthcare.net. Additional program information and referral flyers can be obtained by contacting Jhilleary@AmeriHealthCaritasOH.com.

    PCPs can help combat infant mortality

    You have just confirmed a positive pregnancy on your patient. You have made a referral and facilitated her first OB appointment which is several weeks out. Now what? Submit a Report of Pregnancy (ROP). This is a reimbursable service that notifies the Managed Care Plans of the pregnancy. This will help ensure Medicaid eligibility without loss of coverage. Once AmeriHealth Caritas Ohio receives the ROP we will outreach the member. This can provide a great source of comfort and connection while the member awaits the first OB appointment. 

     

    We can help with the following:

    • Arrange transportation to appointments as needed
    • Connection to our Bright Start Program, AmeriHealth’s program designed specifically for the pregnant person
    • Have access to the Bright Start Team.  A team of Care Managers and Care Guides with specific training in working with pregnant people
    • Assist with WIC connection
    • Assess for food and housing instabilities and provide resources and support
    • Provide education on the importance of dental health in pregnancy and connection with a dental provider if needed
    • Assess for behavioral health concerns and provide linkage to a care provider as needed and desired
    • Assess for future needs such as crib, car-seat, and breast pump
    • Linkage to a specialized texting program where mom- to -be receives informative text education regarding pregnancy each week
    • Review the Prenatal Visit Care Card Incentive of $15 for completed prenatal visits (up to 7 visits)
    Click here for ROP Submission and Billing Instructions. If unable to submit electronically, mail or fax the form to the member's local county JFS office.

      We are seeking providers to serve in advisory roles 

      AmeriHealth Caritas Ohio (ACOH) is seeking providers to serve in advisory roles to shape the Next Generation of managed care in Ohio. Partnering physicians will provide oversight and advise on policies and programs to help patients achieve better health outcomes and reduce the administrative burden for healthcare practitioners. Compensation provided for each meeting participation. Interested in advising? Please contact Bill Walters at wwalters@AmeriHealthCaritasOH.com.

       

      Quality Assessment and Performance Improvement Committee (QAPIC)

      • Purpose: Oversight of ACOH efforts to measure, manage and improve quality of care and services delivered to members/patients.
      • Meetings: Monthly, every 3rd Friday, 7-9 a.m. (subject to change based on provider preference). Meetings are virtual except for one in-person meeting annually.
      • Materials: Delivered electronically one week prior to meeting.
      • Role of external physician: participate in the Quality Improvement (QI) program through planning, design, and implementation/review of the QI program, committee/subcommittees, policy decisions, performance, etc.
      • Ideal candidates: Practitioners with an interest in helping to improve the lives of Medicaid members. Specialty/background in primary care (FM or IM), maternal and infant health (OB/GYN), or behavioral health (MD, DO, PhD).
      • Financial Compensation: $250 per meeting occurrence.

        Provider Advisory Council

        • Purpose: Input into design and improvement efforts for plan programming impacting members and providers. The council will also advise ACOH on clinical improvement efforts, determine options to reduce administrative burden, identify systematic challenges and barriers, problem-solve, share information, and collectively find ways to improve and strengthen the healthcare service delivery system.
        • Meetings: Meetings will occur four times per year, generally in the last week of each quarter. 
        • Materials: Delivered electronically before each meeting with pre-read material usually no longer than five pages.
        • Role of external physician: Provide input and feedback into design of programs and performance improvement efforts.
        • Ideal candidates: Specialty/background in primary care, medical/surgical specialty, or behavioral health provider (MD, DO, PhD) with interest in learning how managed care plans develop clinical quality improvement, reduction in provider administrative burden, healthy disparity reduction efforts.
        • Financial Compensation: $250 per meeting occurrence.

          After-hours healthcare access

          As a friendly reminder, it is very important that those wishing to access healthcare appointments are able to do so at any time. From time to time, patients will reach out to their preferred providers after normal business hours. Please remember to adhere to the minimum standards of after-hour access (M-F after 5 p.m. local time, Sat/Sun 24 hours):

          • If the PCP’s office uses an answering service or answering machine to intake calls after normal hours, the call must be answered by ten (10) rings, and the following information must be including in the message:
            • Instructions for reaching the provider (how to reach the covering physician)
            • Instructions for obtaining emergency care
              • Dial 911
              • Go to the emergency room

            We appreciate all of the time and effort you put in to ensure that your patients, our members, receive the best possible care!

            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.

            NIA is becoming Evolent

            Evolent (formerly National Imaging Associates, Inc.) has consolidated its various companies (Evolent Care Partner; NIA Magellan; Vital Decisions; Evolent Health Services, IPG; and New Century Health) under a single brand: Evolent. This branding change will have negligible impact on providers, but you will start to see logo switch outs from NIA to Evolent on materials. Providers should continue to use RadMD.com to obtain prior authorizations. Phone numbers to reach Evolent will also remain the same as they were for NIA. For future updates, please see RadMD.com.

            Tell us a little bit about where you’re from and where you went to school. I was born and raised in Toledo where I attended Whitmer High School. I moved to Champaign-Urbana, IL for about eight years, where I started my career in health insurance. Upon returning to Toledo, I completed my associates degree in Business Management at Davis College, and then completed my bachelors degree in Healthcare Administration from Mercy College of Ohio.

            Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours? I had worked for another Medicaid managed care plan for about 13 years when I decided to go work with dental providers. However, after some time I realized that my passion truly was working with providers and members in Medicaid space. Upon learning that AmeriHealth Caritas had won the bid for Next Generation Medicaid, I started to do research to find that the company’s goals and mission were very aligned with what I believe and value. I was then lucky enough to run into a former VP who I had worked with at the previous MCE, who was now working at AmeriHealth. During our conversation, he reinforced what I had found during my research about AmeriHealth and I became more interested than ever to join the company. Now two years later, I can honestly say that working here has been one of the most rewarding experiences of my life.
             
            What drew you to this profession?   I knew that I always wanted to work in the medical field, however I soon realized that direct patient care was not for me. Before moving to Illinois I had received my certificate in Medical Billing and Coding with the thought of working in medical billing or health insurance. I was lucky enough upon moving to Illinois the local health plan was hiring for their configuration team and I was hired. What has kept me in this profession is the ability I have to help our members and providers to navigate what sometime can be a difficult landscape.
             
            What do you like to do in your free time? Almost every weekend you can find me antiquing. When I first started out, I

            liked to look around, and maybe pick up anything that “called to me.” However, I quickly fell in love (became obsessed) with vintage Pyrex. I now collect Pyrex from the 1940’s to the 1980’s, mostly bowls and casserole dishes.

              

             

            If you could have dinner with anyone in the world, dead or alive, who would it be? Why?  If I could have dinner with one person it would be my dad. He passed away when I was in my late 20’s, and I would love to be able to sit with him now as an older adult to get to know him in a different way than I did back then. So many questions and life experiences that I would want to ask him about, things that only he would know or advise on.

             

            What are 2 apps on your phone you CANNOT live without?  The apps I cannot live without right now are eBay and Facebook. I use eBay daily to look for Pyrex to add to my collection, while Facebook I use to keep in contact with family and friends.


            Any interesting facts about yourself that you’d like to share?  Halloween is my favorite holiday, and I love anything spooky & paranormal. My husband and I have visited the Mansfield Reformatory several times, with one visit being a night tour. Additionally, I love to visit historically haunted locations like Gettysburg and Salem.

             

            Amy J. Daggett

            Director, Contracting – Ohio

            adaggett@amerihealthcaritasoh.com

            Mobile: 419-205-4933

              Training

            CEU opportunity from AmeriHealth Caritas Ohio!

            Monday, June 17, 9 a.m. – 12:15 p.m.

            Tuesday, June 18, 1 p.m. – 4:15 p.m. 

            Two separate sessions offered via Zoom (register for one)

             

            Kristi L. Enochs, MSW, LCSW,Senior Clinical Training Specialist, AmeriHealth Caritas Family of Companies will present a virtual workshop: Introduction to the American Society for Addiction Medicine (ASAM) Criteria Fourth Edition.

             

            The ASAM Criteria Fourth Edition uses a holistic, person-centered approach to determining the appropriate level of care and developing individualized treatment plans for clients with substance use disorders (SUDs) and co-occurring conditions. This training will introduce core components of the ASAM Criteria, along with Fourth Edition updates to level of care assessment, decision rules, and continuum of care. 

             

            This workshop has been pre-approved for 3.0 CEUs for Ohio Counselors, Social Workers, and Marriage and Family Therapists.

            Provider orientation
            We encourage our new providers to attend one of our virtual orientation sessions. These offer us the opportunity to welcome you, introduce ourselves, and share our unique member benefits, value-based care program, claims and billing information and our provider portal, NaviNet. Join your personal account executives online or contact your local Account Executive to schedule an individual orientation. Click here to see the entire calendar and register.

             

            Don't forget to complete the attestation once you attend a session. The Ohio Department of Medicaid requires us to maintain a registry for the New Provider Orientation attendance

            Cultural competency training
            AmeriHealth Caritas Ohio is committed to promoting education on and awareness of culturally and linguistically appropriate services (CLAS) and to combatting the effects of low health literacy on the health status of our members. There are several training opportunities on our website

            Provider coffee chat

            Thursday, June 20, Noon - 1 p.m.

            Mr. Smith’s Coffee House

            140 Columbus Ave.

            Sandusky 44870

            If you like a cup of coffee with your lunch, come join your Account Executive, Mary Anne Mayle, LISWS. The coffee is on me!  

             

            Tuesday, June 25, 8 a.m. - 9:30 a.m. 

            Sip Coffee (Cricket West Plaza) 

            3160 Markway Rd.  

            Toledo 43606 

            Stop by and have a cup of coffee on your Account Executive, Sara Lajti. My treat!

             

            Thursday, July 18, 7 a.m. - 9 a.m.
            Panera Bread
            9444 Civic Centre Blvd.
            West Chester Township 45069

            Stop by as you head into work. Get to know your Account Executives, Emily Kling and Nicki Fleming. The coffee is on us! 

            Register for Provider Network Management module new features training

            The Ohio Department of Medicaid, in partnership with Maximus, the Provider Network Management (PNM) module vendor, is continuing provider awareness and training efforts around the new features implemented in the Ohio Medicaid Enterprise System.

            Providers will see and utilize these new features in the PNM module beginning on June 30. There is still time to register for the PNM new features training. 

            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, September 19
            • Thursday, November 14
            Click here to register

            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.

             

            Reflecting on PRIDE Month: Health Care Disparities
            People and organizations everywhere celebrate PRIDE month in June – a time to honor and support the LGBTQ community.

            PRIDE month is also an occasion to acknowledge the health care inequality and disparities that this community faces.

            Complexities
            Disparities affecting the LBGTQ community are complex. They intersect with race, ethnicity, age and gender. Some LGBTQ cohorts experience greater discrimination and health inequities than others.
             
            Age
            LGBTQ youth are disproportionately impacted by social determinants of health. These include homelessness and behavioral health issues such as substance use disorder.
             
            Access
            The LGBTQ community also faces increased barriers to health care access and discrimination in treatment. 
             
            Read the complete article.
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