NaviNet dispute process 

Provider claim disputes are any provider inquiry or request for reconsideration. They range from general questions about a claim to a provider disagreeing with a claim denial. 

Disputes can be filed directly with NaviNet using any of the following methods:

• Phone: 1-833-644-6001 (select the prompts for the correct department and then select the prompt for claim issues)
• Online NaviNet
• Mail:
  AmeriHealth Caritas Ohio
  Attn: Provider Claim Inquiry
  P.O. Box 7104
  London, KY 40742
• Fax: 1-833-216-2272

Click here to watch a tutorial video with step-by-step instructions on how to file a claim.

Access the Provider Dispute Submission Form

Sign up for NaviNet

Ohio Department of Medicaid in-person site visits resumed July 1 

The public health emergency has ended, and Ohio Department of Medicaid (ODM) is resuming site visits for initial provider enrollments and revalidations effective July 1. Site visits had been paused without impacting provider enrollment status. Site visits are part of ODM’s provider enrollment screening process and are required by state and federal regulations for certain provider types.

What action do I need to take?

Public Consulting Group (PCG), will be contacting you to schedule a site visit, which may be conducted either virtually or onsite. Please be responsive to PCG when they contact you.

For more information

For questions regarding this notice, please email OH_Provider_Screening@pcgus.com. For more information about provider enrollment and resources check out the Provider Enrollment page on the Ohio Department of Medicaid website.

Defects impacting delivery of 835 files
ODM is aware of issues affecting the provider community’s ability to consistently receive fee-for-service (FFS) 835 files since the Fiscal Intermediary (FI) launch on February 1. ODM understands the importance of timely and accurate data exchange and is committed to ensuring a smooth and reliable user experience. Over the last few months, ODM and its vendors have been identifying and correcting 835-related errors. As a result of the fixes, the majority of missing 835 details have been generated. A large batch was released on May 24, followed by a second batch released on June 26, and another on July 7.

There is one remaining known issue that is currently being addressed. ODM has identified that this issue is primarily affecting hospitals claims. These files cannot be delivered since they failed SNIP edits at the Electronic Data Interchange (EDI). ODM vendors are working on implementing a fix in the coming weeks.

If you have any questions or concerns about this issue, please contact Ohio Medicaid’s Integrated Helpdesk (IHD) at 800-686-1516 or email IHD@medicaid.ohio.gov. Representatives are available 8:00 a.m.- 4:30 p.m. ET Monday-Friday.

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 800-282-0515 or https://www.ohioprotects.org/.

The Electronic Data Interchange (EDI) brings new functionality
One of the new features launched in EDI is the ability to confirm eligibility for specific procedures using CPT/HCPCS codes in the 270/271 inquiry within the EDI. This enables trading partners, on behalf of their providers, to proactively request information about member benefit coverage in addition to Medicaid member eligibility. Providers can work with their trading partners to obtain this information. By using the CPT/HCPCS values in the 270/271 inquiry, providers can obtain crucial information in advance of specific procedures enabling a more streamlined administrative process. 

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-to's, quick guides, links and contact info.

Billing guidelines

Clarifying language is being added to the behavioral health section of our billing guidelines: for services billed under the provider’s primary license, modifiers are not to be used.

Access AmeriHealth Caritas Ohio's provider resources

Step 1: Visit our provider webpage 
Step 2: Sign up for NaviNet
Step 3: Attend a Provider Orientation Meeting
Step 4: Submit claims through Electronic Data Interchange (EDI)