Change in the timely filing rule for EDI submitted claims The Ohio Department of Medicaid (ODM), with the understanding that providers have experienced issues with the Electronic Data Interchange (EDI), is extending the exception to timely filing requirements by two months. They will consider EDI claims that are older than 365 days with a date of service or inpatient discharge date of January 25, 2022, or after, timely if submitted before December 1, 2024.
They will deny any claims older than 365 days submitted after this date.
ODM has resolved most claim submission concerns, resulting in a rejection rate of less than 3% for fee-for-service (FFS) and managed care claims. However, there are still some small pockets of rejection impacting providers. They expect to resolve the remaining claim rejections with the October system update. In order to give providers time to submit any currently held claims, and for those remaining system fixes to be in place, ODM is extending the timely filing requirements, outlined in the Ohio Administrative Code rule 5160-1-19 to begin December 1.
Providers should use the next two months to submit all currently held claims. They understand that some providers are holding claims because they have open tickets with the Integrated Helpdesk (IHD), which they do not recommend. As long as providers submit claims prior to December 1, even if they are denied, ODM can reprocess the claims and have them pay correctly according to Ohio Administrative Code rule 5160-1-19. They require claims with greater than 365 days from the date of service, that are submitted on or after December 1, to be submitted manually through the Medical Claim Review Request (i.e., form 6653). Submitting the claims before December 1 will avoid this additional work.
Claims that are greater than 365 days from the date of service submitted before December 1 must include the appropriate Delay Reason Code in the CLM 20 field. You should select the CLM 20 Delay Reason using the following guidance:
A – Delay Reason Code = 7 (Third Party Processing Delay). Use this code if the claims could not be submitted through the system at all.
B – Delay Reason Code = 9 (Original Claim Rejected). Use this code if the original claim was submitted, but it could not be processed through the OMES system at that time.
Although ODM extended the timely filing requirements, claims submitted after the standard 365-day limit are still subject to post payment review. ODM may verify evidence of system submission issues, such as reviewing past IHD call logs to verify that providers attempted to troubleshoot their issue. If issues are not evident, the claim payment may be reversed.
Trading partners should work with their providers to submit these claims following the updated timely filing requirements.
For any claims other than those that are older than 365 days with a date of service or inpatient discharge date of January 25, 2022, or after, the timely filing requirements and exceptions in Ohio Administrative Code rule 5160-1-19 still apply. If you wish to dispute a claim payment or denial, for fee-for-service claims you should submit the Medical Claim Review Request (i.e., form 6653) and for managed care claims follow the appropriate managed care organization's appeal process.
For additional help For claim assistance, contact the Ohio Medicaid IHD at 1-800-686-1516, option 1, or email IHD@medicaid.ohio.gov. Representatives are available Monday through Friday, 8 a.m. to 4:30 p.m.
275 claim attachment transaction is now available via Availity
AmeriHealth Caritas Ohio is accepting ANSI 5010 ASC X12 275 claim attachment transactions (unsolicited) via Availity.
Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions for payer ID: 84243.
A maximum of ten attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100MB. The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
There are two ways 275 claim attachment transactions can be submitted:
Batch - You may either connect to Availity directly or submit via your EDI clearing house.
If you have questions, please contact Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m.
Submitting disputes with attachments via NaviNet
As of 8/29/24 providers can now submit a dispute with attachments to AmeriHealth Caritas Ohio via NaviNet. To access, go to the Plan Central Home page, Forms and Dashboards and select Provider Disputes.
Check out the updated MyCare Ohio Webpage on Medicaid.ohio.gov! MyCare Ohio is the managed care program designed for Ohioans who receive both Medicaid and Medicare benefits. The MyCare Ohio program integrates Medicaid and Medicare benefits into one program, coordinated by a managed care plan.
To make it easier for you to find the information you need, visit the updated MyCare Ohio webpage.
The Ohio Department of Medicaid is conducting a series of MyCare Ohio program community input sessions to hear about your experiences navigating the current MyCare Ohio program. To learn more about the MyCare Ohio program and community input sessions and view the schedule, please visit the MyCare Ohio program webpage.
Doula trainings
The Ohio Department of Medicaid, the Ohio Board of Nursing, and Medicaid Managed Care Organizations (MCO), will be hosting a training series for doulas. Those interested in providing certified doula services within the State of Ohio, with the intent to serve Ohio Medicaid members, are encouraged to attend. Registration for the training series can be found on the ODM doula webpage.
Training session 3: Tuesday, October 29 from 1:30 p.m. to 3:30 p.m.
MCO claims billing and prior authorization process
Training session 4: Thursday, November 7 from 10 a.m. to 12 p.m.
Fee-for-service billing and prior authorization process
Training session 5: Thursday, November 21 from 12:30 p.m. to 2 p.m.
Related maternal health topics overview
2024 Comprehensive Primary Care (CPC) webinar series with ODM
ODM will virtually share program updates, resources, best practices, and more on November 14. Click here to register.
Ohio Department of Medicaid Resources
New features implemented in the Ohio Medicaid Enterprise System
If your Medicaid patient is contacted for their personal information, advise them not to respond. Report it to the Ohio Attorney General at 1-800-282-0515 or via the online form.
Attend a live, virtual Provider Orientation Meeting
Updated HEDIS guidelines for the Care Gap Closure program
View the HEDIS 2023 Documentation and Coding Guidelines for care delivered in 2024.
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.
Credentialing reminder
Providers no longer need to complete credentialing with each managed care organization. Credentialing is now completed through the state's PNM portal. More information can be found here.
Prior authorizations
New Prior Authorization lookup tool messaging
Effective October 4, as part of the AmeriHealth Caritas Appian deployment to connect Appian and the Prior Authorization lookup tool, there is a new message in the tool.
If a code is not on ODM's fee schedule, this message will appear:
This code is not on the Ohio State Medicaid Fee Schedule and prior authorization is required. Please submit your request with supporting clinical documentation through NaviNet (https://navinet.navimedix.com).
If the code is on ODM's fee schedule, the appropriate message will populate.
The fee schedule check is against Facets and is the same function that is used in the rule engine for decisioning. Thus, the fee schedule updates are as frequent as they are updated in Facets.
Out of network providers
Contact Utilization Management for a prior authorization prior to providing care to our members: 1-833-735-7700. Additionally, if interested in joining our network please reach out to our Contracting department via email at: providerrecruitmentoh@amerihealthcaritasoh.com. This email address can also be used by vision providers looking for in-network vendors who can provide for eye glass frames and lenses.
Submitting prior authorization (PA) requests for behavioral health services
See the new tip sheet for guidance on submitting PAs for behavioral health service requests.
Submit prior authorization requests (PA) 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
Submit all medical pharmacy prior authorizations (PA) to PerformRx
Prior authorization requests for prescriber administered medications should be submitted to PerformRx via fax. See our website for more information and the form.
Prior authorization lookup tool
As a reminder, to verify whether a service requires prior authorization, use the Prior Authorization Lookup Tool on the provider website.
NOTE: Prescriber-administered medications that are billed via the medical benefit (CMS 1500 or UB-04) are reviewed by our PBM, PerformRx. Prior authorization request for prescriber administered medications should be submitted to PerformRx via fax. You can download a form here to submit via fax.
Questions? Contact your Provider Network Management Account Executive or Provider Services at 1-833-644-6001.
Claims and billing
Questions about reimbursement or payment policies?
Click the appropriate link below for detailed information.
Providers are expected to submit their usual and customary charge (the amount charged to the general public) on all claims. The medicaid payment amount for a covered service, procedure, or supply is the lesser of the submitted charge or the established medicaid maximum. Therefore, providers should always submit their designated charges to avoid underpayment or rejections.
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
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.
Claims Payment Systemic Error (CPSE) report
The Claims Payment Systemic Errors (CPSE) report is updated and posted monthly on our website. 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.
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.
For additional information regarding these updates, including who to contact at each MCO for questions, see the quick reference guide on our provider website.
AmeriHealth Caritas Ohio offers novel approach to reach communities
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.
We are pleased to offer this convenience at no cost to you and your community.
We welcome the chance to collaborate with you to help people get care, stay well, and build healthy communities.
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.
Provider coffee chat Stop by and have a cup of coffee with your Account Executives, Brenda Allen and AZ Patterson. Their treat!
Thursday, November 7
8:00 a.m. to 10 a.m.
Starbucks at House Three Thirty
532 W. Market St.
Akron, Ohio 44303
Summit County
100 credits remaining
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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.
Pain Self-Management Education (PSME) program
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.
Tell us a little bit about where you are from and where you went to school.I’m from Atlanta, GA and still all about Atlanta sports =). I moved to Cincinnati in 2009 to attend Xavier University for grad school, while there I met my wife and we’ve been here ever since.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?I have worked for a large health system and another Medicaid Managed Care Plan in Ohio. What excited me about AmeriHealth Caritas Ohio was the opportunity to do something new with a new plan and not necessarily do what’s just been the standard managed care work but get outside the box. We can think differently being new and that’s what I feel like is needed in the ever-changing healthcare landscape. I previously worked with our Market CEO, so that made it easier to make the jump to a new plan as well.
What drew you to this profession?I was in healthcare when I got out of undergraduate school, but it was financial planning and sales related. I wanted to be in healthcare to help people and use my economics degree, which led to graduate school at Xavier for a Master of Healthcare Administration degree.
What do you like to do in your free time? Spending time with my wife, daughter (4), and a Great Pyrenees-Doodle named Zeus. We will be adding another little girl to the mix in November. When I can, I like to play golf, hike, and travel. I also like watching all sports, but especially Xavier basketball, Atlanta Braves baseball, and Atlanta Falcons football.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?Being an avid golfer and from Atlanta, I’m going to go with Bobby
Jones. He is arguably one of the most influential figures in sports history. Not only was he the most successful amateur golfer, but he also designed Augusta National Golf Course and co-founded The Masters Tournament. The Masters is by far my favorite golf tournament and golf course. I’ve been fortunate to visit but would love to learn more from him about the course and tournament he created. Outside of golf, Bobby holds degrees from Georgia Tech and Harvard Law and served in WWII, even though his superiors tried to keep him in the states to play golf – which would make for interesting conversations as well.
What are 2 apps on your phone you CANNOT live without? Weather and X (formerly Twitter).
Any interesting facts about yourself that you’d like to share?I’m proud to say I’ve hit two holes-in-one playing golf. One was extra special because I was playing with my brother and father.
Me and my daughter, Gracyn. She is a big fan of driving the cart and eating snacks while occasionally putting with me.
Robert Metzler
Manager, Provider Network Management
rmetzler1@amerihealthcaritasoh.com
1-614-616-2770
Did you know October is National Physical Therapy Month? Each year National Physical Therapy Month is celebrated to raise awareness about the many benefits of physical therapy. This year, the American Physical Therapy Association is emphasizing the vital roles physical therapists and physical therapist assistants play - across all specialty areas and patient populations - in falls awareness, prevention and recovering from falls-related injuries.
Make October a moving experience!
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