Welcome to the July newsletter!
July 2023
Prior authorizations
Did you know you can submit prior authorizations through the NaviNet portal?
AmeriHealth Caritas Ohio created this tool to provide a higher auto-approval rate and quicker turnaround time compared to faxing the authorizations. There is also a report function that gives a status report allowing you to have visibility to all prior authorization requests you have submitted.
We are happy to offer training or any assistance your team may need to transition to this process. Please reach out to your local Account Executive.
Value-added benefits - Mission GED Program

Mission GED is a special program that can help your patients, our members, reach their goal of achieving their high school equivalency (HSE) diploma. AmeriHealth Caritas Ohio will provide testing vouchers so they can take tests for an HSE diploma at no cost to them. We can even provide a program coach to offer support and encouragement on their journey.

To enroll in Mission GED, the following requirements must be met:

  • Be a current AmeriHealth Caritas Ohio member
  • Be 16 years or older (parental consent needed for members 16 and 17 years of age)
  • Not have a high school diploma or equivalent
  • Not be currently enrolled in high school or college

Have patients ready to apply?

Download the Mission GED application or call 1-833-764-7700 (TTY 1-833-889-6446) to get started.

Mail the completed application to:

AmeriHealth Caritas Ohio
c/o Member Services
5525 Parkcenter Circle, Suite 100
Dublin, OH 43017


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. 


Attaching documents to a claim

To attach a document to a claim, you will need to access the Medicaid Information Technology System (MITS) portal via the Provider Network Management (PNM) module. This Quick Reference Guide can assist with accessing the self-service functions in MITS via the PNM.


For assistance with attaching documents to a claim submitted through the MITS portal, providers can refer to item #4 in the Web Portal section of this document.


Check out new Ohio Medicaid micro videos

ODM has developed a variety of short videos to help members, providers, stakeholders, and advocates better understand Ohio Medicaid and the Next Generation program. Each video explains an important topic and provides resources for additional information or where to go with questions.


COVID-19 vaccination billing

For hospital and institutional providers billing for COVID vaccinations, if you are billing the following vaccine administration CPT codes, the payment will be capped at the lesser of billed charges or fee schedule amount. To bypass the grouper packaging logic and receive payment, ODM is requiring the vaccination administration codes to be billed using RCC 771 with modifier HE. 


0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0041A, 0042A, 0044A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0124A, 0134A, 0144A, 0154A, 0164A, 0173A and 0174A


Find ODMs COVID-19 billing guidelines here.

Resources and reminders
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-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)

Claims Payment Systemic Error (CPSE) Report

The Claims Payment Systemic Errors (CPSE) report is updated and posted on the ‘Alerts and Newsletter’ page monthly. AmeriHealth Caritas Ohio encourages you to review this log frequently and before contacting our Provider Services team. If after reviewing you still have additional questions, please feel free to reach out to Provider Services at 1-833-644-6001 and, as always, you can reach out to your local account executive.

Billing evaluation and management services with behavioral health evaluation codes
To improve the integration of behavioral medicine with physical medicine, AmeriHealth Caritas Ohio (ACOH) is taking steps to make it easier for providers to make an impact in their community. 
In an effort to reduce administrative burden and expand access to behavioral health services, ACOH will reimburse claims for evaluation and management services and behavioral health evaluations, when the level of care warrants the usage of the behavioral health evaluation and documentation supports that these services are separately identifiable, in accordance to Ohio Administrative code 5160-27.03 and Appendix A, 5160-27-03.

How this impacts billing:

  • If the evaluation meets the 30 minute minimum for the following time based codes:  90832, 90836, or 90838, providers can bill with them with same day/ same physician services rendered for codes 99201-99215
  • If the services do not meet the requirements to bill for E/M and full BH Evaluation, providers have the option to bill for a higher level E/M code or utilize 90792, in accordance with CMS guidance: “When a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed. If a psychiatric diagnostic evaluation with medical assessment is performed, the physician or NPP may use CPT code 90792 or an evaluation and management (E/M) code.”

Sign up for a new provider orientation session

AmeriHealth Caritas Ohio has added provider orientation sessions through the end of the year. Join your personal account executives online via Zoom from 10 a.m. - 11 a.m. on any of the dates below.


New provider orientations inform our providers about Next Generation and Plan updates, claims and billing resources, prior authorizations resources, EFT information, and member and provider resources. 


July 18 - click here to register

August 15 - click here to register

September 19 - click here to register

October 17 - click here to register

November 14 - click here to register

December 19 - click here to register


Have you attended an orientation session and need to complete the attestation? Click here to get started.

Tell us a little bit about where you’re from. I was born and raised in Akron and graduated from East High School. I earned my B.A. from the University of Mount St. Joseph in Cincinnati.


Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours? I had been working in the healthcare industry for many years, mainly in community outreach and marketing, but always had a desire to work in the Provider Relations/Services area. I was very excited and pleased when I was given the opportunity to join the Provider Services team at AmeriHealth Caritas Ohio.


What do you like to do in your free time?  I am an avid gardener. I love to see flowers, herbs and vegetables grow and how fulfilling it is to reap the harvest and share the bounty with family and friends. I enjoy riding my eBike and playing pickleball too!


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 Sidney Poitier who appeared to be a true gentleman, well-educated and with very impressive acting skills.


What are two apps on your phone you CANNOT live  without? PictureThis, which is a plant identifier app, allows me to determine the name and care of various plants. The Solitaire app is fun when I just want to idle away some time!


Any interesting facts about yourself that you’d like to share? I have worked as a missionary in Africa – visiting the areas of Malawi, Zambia, Zimbabwe, Mozambique, Swaziland, Lesotho, Rwanda, Namibia, and South Africa – Soweto, Cape Town and Johannesburg.


Brenda on a mission in Africa

Minority Mental Health Awareness Month

National Minority Mental Health Awareness Month is observed each July to bring awareness to the unique struggles that racial and ethnic minority communities face regarding mental illness in the United States.

Racial and ethnic minorities often suffer from poor mental health outcomes due to multiple factors, including lack of access to quality mental healthcare services, cultural stigma surrounding mental healthcare, discrimination, and overall lack of awareness about mental health.

Throughout the month, the Health & Human Services (HHS) Office of Minority Health (OMH) will focus on promoting tools and resources addressing the stigma about mental health among racial and ethnic minority populations, particularly during the COVID-19 pandemic.

OMH encourages state, tribal, and local leaders, community-based organizations, faith leaders, healthcare providers and individuals to educate your communities regarding mental health stigma.

Upcoming webinars
Improving Outcomes for People with Disabilities 2023 virtual roundtable
Ohio Association of Health Plans and Ohio Center for Autism and Low Incidence (OCALI) are hosting a series of virtual roundtables. This series provides attendees the opportunity to hear from and engage with national experts and local leaders and deepen their understanding of people with disabilities as a focus of population health. The one-hour roundtables include lived experience, didactic presentation, and opportunity for interaction. Each session is designed to both challenge your thinking and change your practice, providing you with tools and resources you can use immediately. Click here to register. 
Connect with us
View this email in your browser
You are receiving this email because of your relationship with AmeriHealth Caritas Ohio. Please reconfirm your interest in receiving emails from us. If you do not wish to receive any more emails, you can unsubscribe here.
This message was sent from comms@amerihealthcaritasoh.com to comms@amerihealthcaritasoh.com
5525 Parkcenter Circle, Suite 100, Dublin, OH, 43017

Update Profile/Email Address