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Provider Services 1-833-644-6001 |
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Provider coffee chat
Stop by and have a cup of coffee with your Account Executive, Brenda Allen. Her treat!
Thursday, March 13
8:00 a.m. to 10 a.m.
Starbucks at House Three Thirty
532 W. Market St.
Akron, Ohio 44303
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Ohio Department of Medicaid (ODM) updates
To stay up to date on ODM news, subscribe to the ODM Press.
Provider training
The Ohio Department of Medicaid, in partnership with Maximus, the Provider Network Management (PNM) module vendor, is continuing provider training from February 18-26. The schedule is available here. Click to read the entire article.
Tips for contacting the Ohio Medicaid Integrated Helpdesk
The Integrated Helpdesk (IHD) is a great resource to use when you run into an issue. It provides 24 hour, 7 days a week access to information regarding client eligibility, claim and payment status, and provider information. Read the useful tips here.
Important 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 for claims
Following an analysis of claims data ODM has determined it necessary to extend the timely filing deadline to March 1. 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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DentaQuest pre-payment review update
Effective March 1, the pre-payment review requirement will be removed for procedure code D9230 (inhalation of nitrous oxide/analgesia, anxiolysis) for AmeriHealth Caritas Ohio Medicaid members ages 20 and under. Please be aware that this service is subject to medical necessity criteria and retrospective review. Although the narrative requirement has been removed, we strongly encourage providers to maintain documentation of medical necessity, which can be included in the claim submission.
If you have questions or need assistance, call the Ohio Provider Services line at 1-855-398-8411, reach out to your Provider Partner directly, or email the Provider Engagement team: OHProviderEngagement@DentaQuest.com.
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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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
Questions regarding The American Society of Addiction Medicine Criteria Fourth Edition, Volume 1 – Adults
- Does ODM have a date in mind for adopting the Fourth Edition Criteria into Ohio Medicaid coverage and reimbursement policies? Given the extent of the changes included in the Fourth Edition, Volume 1 – Adults, the Department will not establish a timeline for implementation until it has completed the review and stakeholder engagement processes.
- What criteria will the managed care entities use when rendering a decision on a prior authorization request? Medicaid managed care entities will use the Third Edition Criteria when rendering a decision on a prior authorization request for SUD services until ODM formally adopts use of the Fourth Edition Criteria, Volume 1 – Adults. If a provider chooses to move towards the adoption of the Fourth Edition criteria prior to the State’s adoption, the provider must ensure that a request for PA meets the Third Edition criteria.
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.
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Bright Start® maternity program
Bright Start helps our members stay healthy when they are pregnant and have a healthy baby. Members get access to our pregnancy care program to help schedule appointments and connect to community resources and additional programs. Visit the links below to learn more about this valuable program for your pregnant patients.
Care for Pregnant Members
Bright Start Welcome Booklet
Bright Start Beginnings Bundle
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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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AmeriHealth Caritas Ohio Provider Resources
Our user-friendly tools and resources are designed to support Ohio’s Medicaid providers and your staff in giving members excellent and efficient healthcare. Visit our website for a list of resources available to your office.
Updated HEDIS guidelines for the Care Gap Closure program
View the HEDIS 2024 Documentation and Coding Guidelines for care delivered in 2024.
Provider Network Management (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 virtual New Provider Orientation sessions. 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 was born and raised in Chattanooga, Tennessee. I am a proud Ooltewah Owl and attended college at Sinclair in Mason, Ohio.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?
I heard a buzz in the MCE world about a new Medicaid plan entering the Ohio market and started looking at the opportunities. I was impressed by leadership during the interview process and wanted to be a part of it!
What drew you to this profession? I am very organized with my work.
I started working in managed care shortly after high school when my aunt told me how much she loved her career. This career gives me an opportunity to help others and I have always been passionate about that.
What do you like to do in your free time?
I love spending time with my 5 year old daughter Elliot and riding my motorcycle.
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If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
Lytha Robinson. My Mamaw who passed away when I was 20. She taught me so much and it made me who I am today.
What are 2 apps on your phone you CANNOT live without?
TikTok and Instagram.
Any interesting facts about yourself that you’d like to share?
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I collect vintage Harley and concert tees. I have a rare Guns and Roses tee that was banned and pulled off the shelves shortly after production. The last time I checked, it is worth around 2K.
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I was diagnosed with Breast Cancer in May of 2023 and am now a survivor!
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One of my motorcycles is older than me!
Amanda Robinson
Provider Network, Account Executive II
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American Heart Month
Heart disease is the leading cause of death for men and women in the United States. Most middle-aged and young adults have one or more risk factors for heart disease, such as diabetes, high blood pressure, high cholesterol, or being a smoker or overweight. Having multiple risk factors increases the risk of heart disease. The good news is that there’s a lot we can do to prevent it. Find fact sheets, flyers, and tools here to share with your patients.
Rare Disease Day
Ohio will have several events to raise awareness of sickle cell disease, including Rare Disease Day, a symposium, and blood drives. On February 28, the Ohio Sickle Cell and Health Association will participate in the 18th annual Rare Disease Day. This global event aims to improve access to healthcare, diagnosis, and therapies for people with rare diseases. |
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Need help?
AmeriHealth Caritas Ohio Provider Services is ready to help.
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