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Provider Services 1-833-644-6001 |
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Required annual education for EPSDT-HEALTHCHEK
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 Ohio Medicaid. Healthchek covers 10 checkups in the first two years of life and annual checkups after age 3.
EPSDT benefits includes a range of medically necessary screening, diagnostic, and treatment services to prevent, diagnose, treat, evaluate, correct, or ameliorate adverse health conditions including illness, injury, emotional or behavioral dysfunction, intellectual deficits, cognitive impairments, or developmental disabilities.
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
The Well Child Visit Schedule recommended by American Academy of Pediatrics (AAP) is listed below. To view the comprehensive Periodicity Schedule for Preventative Health Care, click here.
| 2 - 5 days old |
1 month old |
2 months old |
| 4 months old |
6 months old |
9 months old |
| 12 months old |
15 months old |
18 months old |
| 24 months old |
30 months old |
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| Every year until age 21 |
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Ohio Department of Medicaid (ODM) updates
To stay up to date on ODM news, subscribe to the ODM Press.
Reminder: Update 1099 address information in the Provider Network Management module
It is important that providers update all 1099 address information in the Provider Network Management (PNM) module on a regular basis. Ensure all information is current, including extra address details like suite number, house/office number, etc. to reduce the chance of non-delivery by the postal service. Access the quick reference guides here.
Extended: timely filing notice
Following an analysis of claims data ODM has determined it necessary to extend the timely filing deadline to March 1, 2025. To ensure a consistent experience for providers of Medicaid services, AmeriHealth Caritas Ohio will follow this guidance and extend the deadline.
New features implemented in the Ohio Medicaid Enterprise System
The New Features Implementation Overview outlines key changes for providers.
Medicaid agreement revalidations
To complete revalidation, visit PNM & Centralized Credentialing.
Ohio Department of Medicaid fraud warning
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.
Updated claim submission and adjudication FAQ
Claims and Prior Authorization Submission Frequently Asked Questions (FAQ)
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Ohio Department of Medicaid email links
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 Claims and billing |
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Connectivity restored with Optum/Change Healthcare
The restoration of connectivity with Optum/Change Healthcare gives our providers options for claims submissions. Click here to learn more about the electronic and manual/direct entry options.
Questions about reimbursement or payment policies?
Click the appropriate link below for detailed information.
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.
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 reach out to Provider Services at 1-833-644-6001 and, as always, you can reach out to your local account executive.
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.
For additional information regarding these updates, including who to contact at each MCO for questions, see the quick reference guide on our provider website.
Submitting claim disputes on NaviNet
If a Provider disagrees with the outcome of a claim, the first step should always be to submit a claim dispute. This can be done via fax and online. Below are the steps to submit a claim dispute on our NaviNet portal:
Although the dispute is being submitted online, all resulting correspondence will still be received via mail.
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 Prior authorizations |
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Prior authorization requirement changes
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Title
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Codes
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Change
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Eff. date
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| J3490 |
J3490
(Unclassified drugs)
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Authorization required if >$750 |
02/09/2025 |
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81511
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81511: Fetal congenital abnormalities, biochemical assays of four analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal serum, algorithm reported as a risk score (may include additional results from previous biochemical testing)
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No prior authorization required
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12/01/2024
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As a reminder, to verify whether a service requires prior authorization, use the Prior Authorization Lookup Tool on the provider website. Remember, you can save time by submitting your medical authorizations electronically via NaviNet.
Questions? Please contact your Provider Account Executive or call Provider Services at 1-833-644-6001.
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.
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 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.
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For Behavioral Health Providers
CEU opportunities
Sign up to receive email about AmeriHealth Caritas Ohio’s free continuing education unit (CEU) opportunities.
Ohio Department of Medicaid Introduces Mental Health Peer Support Services
New service added to the growing list of behavioral health resources available to Ohioans.
Submitting prior authorization (PA) requests for behavioral health services
See the new tip sheet for guidance on submitting PAs for behavioral health service requests.
Statewide registry of recovery housing residences
The Ohio Department of Mental Health and Addiction Services released a public-facing registry of recovery homes in early November. Starting January 1, 2025, only homes on this registry may receive referrals from mental health and addiction services providers. Providers should check this registry and ensure that any homes that they regularly refer individuals to are listed on the registry. If they are not, those individuals need to take the needed steps to ensure that they are on the registry by January 1, 2025. Only homes that are appropriately accredited may be on the registry. The two entities that are providing the accreditation are Ohio Recovery Housing, which offers a certification, and Oxford House, which charters recovery homes. For more information contact Ohio Recovery Housing at 1-614-453-5133 or visit info@ohiorecoveryhousing.org.
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We are now covering doula services
AmeriHealth Caritas Ohio is dedicated to improving health outcomes for pregnant Medicaid members. Any pregnant or postpartum person with Medicaid coverage is eligible to receive doula services from a Board of Nursing-certified, Medicaid-enrolled doula. Doulas have been shown to improve birth outcomes, support birth equity, positively impact the social determinants of health, and reduce disparities in maternal and infant outcomes.
Click here to read the coverage overview, visit types, and find resources.
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 Resources and reminders |
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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.
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 Training opportunities |
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New Provider Orientation Schedule
You and your office staff are invited to join us for a virtual New Provider Orientation session on January 21 at 10 a.m.
These orientations are designed not only to familiarize you with the vast resources available to you through our website, but also to identify areas of importance to help you work with us to best serve our members — your patients.
Your personal AmeriHealth Caritas Ohio Account Executives look forward to meeting you! 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.
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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. |
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Tell us a little bit about where you’re from and where you went to school.
I am from Dayton and went to school at Stebbins High School.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?
I have a Medicaid background and AmeriHealth Caritas Ohio was a growing company with great opportunities.
What drew you to this profession? I am very organized with my work.
I like to dive deep into issues and resolve them.
What do you like to do in your free time?
Spend time with my kids, travel, and cook.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
Liam Neeson, he is my favorite actor.
What are 2 apps on your phone you CANNOT live without?
TikTok and Facebook |
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Any interesting facts about yourself that you’d like to share?
I have 4 kids under the age of 6.
Emma, Malcolm,
Maxwell, and Myles having fun in the snow!
Mattie Pietrzak
Provider Network Account Executive
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Need help?
AmeriHealth Caritas Ohio Provider Services is ready to help.
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