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Provider Services 1-833-644-6001 |
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Today - join ODM for the first all-provider, all-MCO semi-annual meeting
The meeting is a collaboration between all seven Medicaid Managed Care Organizations in Ohio to support providers enrolled in the Comprehensive Primary Care (CPC) and Comprehensive Maternal Care (CMC) programs. This meeting can also help support providers interested in participating in both programs.
Wednesday, March 19
Noon - 1:30 p.m.
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New Home Health Aide Training Program
To support meaningful employment for Medicaid enrollees, AmeriHealth Caritas Ohio has launched a new benefit for plan members, the Home Health Aide (HHA) Training Program. Administered by the Ohio Council for Home Care & Hospice, the program provides cost-free training and certification to AmeriHealth Caritas Ohio members seeking to become employed as an HHA. This new member benefit promotes and supports meaningful employment opportunities for Medicaid enrollees and addresses the need for more home health aides in Ohio.
AmeriHealth Caritas Ohio is seeking home health agency partners to support a member’s successful completion of this program. Specifically, the home health agencies would be responsible to administer an exam and facilitate a skills assessment.
Partner with us today to increase your pool of eligible HHAs that meet both CMS and PASSPORT requirements!
Contact Carmen Clutter, Director, Population Health Management for additional details.
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Ohio Department of Medicaid (ODM) updates
To stay up to date on ODM news, subscribe to the ODM Press.
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.
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.
Electronic data interchange
Providers with electronic data interchange (EDI) capabilities may submit claims, eligibility inquiries, claim status inquiries, and associated attachments by being a trading partner authorized by ODM or by contracting with an ODM-authorized trading partner. For more information, visit the ODM trading partners webpage or call the ODM IHD at 1-800-686-1516.
Direct Data Entry
For Direct Data Entry (DDE), providers should log in to Change Healthcare using the tool called ConnectCenter to improve claims management functionality. Providers who have a limited ability to submit claims through their hospital or project management system may now benefit from key features of the ConnectCenter tool. There is no cost to providers to use ConnectCenter. Learn more on our claims and billing webpage.
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.
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 via fax or 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.
Providers can submit a dispute with attachments to AmeriHealth Caritas Ohio via NaviNet. Providers have the option to submit disputes through NaviNet, instead of faxing or mailing. We recommend providers use this option. Log into NaviNet, go to Forms & Dashboards, scroll down to Provider Disputes, then click on the Submit Provider Disputes link. Turnaround time is 15 days for disputes.
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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.
To read the Ohio Medicaid Managed Care Organizations Consolidated Doula Resource Guide click here.
The Ohio Board of Nursing has released a new State of Ohio Certified Doula FAQs document, providing key information on certification requirements, scope of practice and other essential details for doulas in Ohio.
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 Resources and reminders |
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Sign up for this newsletter
Our monthly newsletter, Provider Partnerships, keeps you informed about plan news, updates, and resources. Click here to sign up.
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.
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 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 opportunties
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. |
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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 Columbus.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?
When the opportunity for a new health plan arose, I jumped on the opportunity to “jump ship” to help a new plan become a pillar for Medicaid. I loved the mission of AmeriHealth Caritas Ohio and wanted to be a part of it.
What drew you to this profession?
I have always been drawn to help the underserved. Helping with this population gives me a sense of purpose.
What do you like to do in your free time?
Exercise and watch any sport but my heart lies with The Cleveland Cavaliers, The Cleveland Browns, and Ohio State Football. |
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If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
Barack Obama. I would love to pick his brain regarding his upbringing, how he felt about becoming the first Black president, and what he occupies his time with now that he is no longer president.
What are 2 apps on your phone you CANNOT live without?
Facebook and ESPN.
Any interesting facts about yourself that you’d like to share?
I have two full sleeve tattoos and I can speak Pig Latin.
Wendy Woodson
Provider Network Account Executive II
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March is National Kidney Awareness Month
Chronic kidney disease is best identified and treated early as part of comprehensive primary medical care. Goals of medical management are to identify, monitor, and treat complications while providing patient education on diet and lifestyle habits, and patient
preparation for renal replacement therapy.
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) provides resources for healthcare professionals, including practice tools for the diagnosis and treatment of diabetes, digestive diseases, liver disease, kidney disease, and obesity, and educational resources that support patient self-management. Click here for more information. |
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Need help?
AmeriHealth Caritas Ohio Provider Services is ready to help.
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