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Provider Services 1-833-644-6001 |
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Win lunch for your office!
AmeriHealth Caritas Ohio wants to ensure we are providing you with the best service as you care for your patients, our members. We have developed a very short survey to better understand our opportunities for improvement. Each completed survey will earn you an entry into a drawing for a free lunch for your entire office!
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About the Provider Master File
To better serve our provider network, AmeriHealth Caritas Ohio has accepted rosters from providers as an additional level of validation against the Provider Master File (PMF) data.
Since the source of truth launch in October 2023, AmeriHealth Caritas Ohio has been monitoring its network providers and their utilization of the PMF. It has been noted that the majority of providers are now maintaining their records through the source of truth.
On July 1, AmeriHealth Caritas Ohio ceased all reconciliation efforts using rosters unless contractually obligated to do so. We encourage all providers to update their information in the PNM to ensure the most up to date information.
Best practices to ensure accurate payment and directory information
- Make sure provider records are current in the Provider Network Management (PNM) module.
- Providers should review and update their information regularly in the PNM module. AmeriHealth Caritas Ohio suggests at least monthly to avoid any payment issues.
- Provider specialties should be updated and captured as well as primary locations.
- When making changes, AmeriHealth Caritas Ohio recommends that providers allow time for updates from the PNM to populate in the Provider Master File.
- ODM can take up to 14 business days to approve and send changes to MCOs.
- If you are having difficulties getting your claims to AmeriHealth Caritas Ohio through the Fiscal Intermediary (FI), contact the Integrated Helpdesk at ODM 1-800-686-1516 or at IHD@Medicaid.ohio.gov.
- Providers can always request a reconciliation roster from their Provider Services Account Executive to make sure that data is being correctly reflected within our system and directories.
- Review panel changes, or your ability to accept new patients with your account representative to reduce patient abrasion.
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Electronic Visit Verification denial codes are live!
As a reminder, on June 1 denial codes went live for Home Health services. Beginning August 1, denial codes will go live for Private Duty nursing services and other home-based nurse services. For more information about electronic visit verification (EVV), you can visit our website, ODMs Electronic Visit Verification page, or call us at 1-833-644-6001.
Beginning August 1, your claims requiring electronic visit verification must have a matching EVV visit record in Sandata. Claims that do not match will be denied.
Upcoming changes will include private duty nursing, and nurse assessment and consult services billed to managed care organizations (MCOs). As we continue to implement changes to Ohio’s EVV program, it is essential that you remain aware of the potential implications for your claim submissions.
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Service Description
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Service Code
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Private Duty Nursing
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T1000
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Nurse Assessment and Consult
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T1001, T1001_U9
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Daily office hours, training webinars, and online resources are available to you. Look for emails announcing trainings from HHA/Sandata and visit Medicaid.ohio.gov/EVV for more tools to help you transition smoothly.
As this change goes into effect, remember:
- Review Guidelines: Familiarize yourself with EVV requirements and guidelines. Ensure that you and your staff are trained and equipped to handle these changes effectively.
- Verify Claim Submissions: Double-check that all claims are submitted with correct data that matches with a captured visit, including service dates, provider ID, and recipient information. Missing or incorrect data will lead to denials.
- Utilize Available Resources: Take advantage of training sessions, webinars, or resources provided by our organization and ODM to help you navigate EVV.
- Monitor Claims Status: Regularly check the status of your claim submissions to identify any issues early. Prompt action can often resolve potential problems before they escalate.
You can find all the resources mentioned above at Medicaid.ohio.gov/EVV. If you have any questions or need further clarification on EVV claims processing changes, please do not hesitate to reach out to the EVV Provider Hotline at 1-855-805-3505. You can also call or email the ODM Integrated Help Desk (IHD) at 1-800-686-1516 or IHD@medicaid.ohio.gov.
Our goal is to support you through this transition and ensure that you are fully informed about the changes that may impact your claims. We appreciate your cooperation and commitment to providing high-quality services to our members. If you have questions or concerns, please contact AmeriHealth Caritas Ohio at 1-833-644-6001.
Please note the services and provider types that are subject to Electronic Visit Verification and the corresponding implementation phases. All providers must comply with ODM policy around verification, or they could experience denials beginning June 1.
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Our Medicaid benefits go far beyond medical coverage. Click here to learn about our special programs and extra benefits like financial assistance for school supplies and even trade school uniforms, transportation, housing help, and a bundle of goodies for new moms and babies.
AmeriHealth Caritas Ohio knows that getting an education plays a role in overall well-being. That’s why we offer a |
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valuable benefit to help cover the cost of school uniforms and school supplies.*
How it works
Each AmeriHealth Caritas Ohio member who is in school can get up to $75 a year to buy school uniforms and school supplies. This can be for things such as: K–12 school uniforms (shirts, pants, skirts, socks, shoes, etc.). |
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- Vocational supplies:
- Aprons
- Smocks
- Lab coats
- Scrubs
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- School supplies:
- Backpacks
- Crayons
- Folders
- Highlighters
- Index cards
- Markers
- Notebooks
- Pencils and pens
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You can also call AmeriHealth Caritas Ohio Member Services at 1-833-764-7700 (TTY 1-833-889-6446), 24 hours a day, seven days a week. Or visit us at www.amerihealthcaritasoh.com.
*Some restrictions and limitations may apply.
Note: This benefit cannot be used to buy scissors. |
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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, seven days a week access to information regarding client eligibility, claim and payment status, and provider information. Read the useful tips in this newsletter.
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 regularly. 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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Manual/direct entry claims
Providers may submit manual/direct entry claims via:
- Optum/Change Healthcare ConnectCenter™
- This option is currently only available for providers who had an established account prior to the security incident. Access to the portal and usernames will remain the same but a password reset, and multi-factor authentication are required.
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.
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 more 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 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. The turnaround time is 15 days for disputes.
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 Prior authorizations |
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Important Update: Prior Authorization Requirements
There are no changes to home and community-based waiver processes, nor to managed care processes.
Beginning August 1, the Ohio Department of Medicaid will deny claims submitted without an approved prior authorization under the Fee-For-Service (FFS) policy. This change is critical to ensure compliance with Ohio Medicaid’s updated requirements.
To help you prepare for this transition, ODM has developed a comprehensive support plan:
- Training Opportunities: Beginning June 25 through August 5, ODM, in partnership with PNM and FI, will offer 10 two-hour training sessions. These sessions are designed to walk through the updated prior authorization process. We strongly encourage all providers to attend at least one session.
- Warning Period: On July 1, claims submitted without the required prior authorization will receive a detailed warning in the remittance advice. This is your opportunity to correct submissions before denials begin.
- Enforcement Begins: On August 1, claims without proper prior authorization will be denied.
You can read the entire press release, learn more about the PNM module and prior authorization, and register for training by clicking here.
Out of network providers
Contact Utilization Management for a prior authorization before providing care to our members: 1-833-735-7700. If you are interested in joining our network, contact our contracting department: providerrecruitmentoh@amerihealthcaritasoh.com. This email address can also be used by vision providers looking for in-network vendors who can provide eyeglass 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 (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 |
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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.
Submitting prior authorization (PA) requests for behavioral health services
See the tip sheet for guidance on submitting PAs for behavioral health service requests.
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Resource for behavioral health consultations launching for primary care providers
In July 2025, the Ohio Pediatric Psychiatry Access Line (OPPAL) launched, offering pediatric primary care providers in Ohio access to a telephone helpline for same day, convenient peer to peer consultation with child psychiatrists. OPPAL’s introduction compliments other actions taken in Ohio to address rising mental health needs among youth, as new data continues to shed light on areas of need and gaps in care. Learn more about OPPAL by clicking here.
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 Resources and reminders |
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Free Ohio State Fair admission for behavioral health workers
On Friday, July 25, OhioMHAS will celebrate the dedication and tireless efforts of Ohio’s behavioral health workforce as part of RecoveryOhio's Fourth Annual Mental Health Day at the Ohio State Fair.
As a token of appreciation, OhioMHAS is offering free fair admission to members of this vital workforce.
Click to claim ticket: RecoveryOhio Mental Health Day at the Ohio State Fair Survey
Multi-Factor Authentication for Care Coordination Portal Access
To increase protection for the Managed Care Organization Care Coordination Portal’s and member information data, signing in will soon require Multi-Factor Authentication (MFA). MFA is a two-factor authentication process that takes user verification a step beyond the State of Ohio (OHID) and password. This is done by using a second source of validation (i.e. text message, email, passkey, phone call) to verify user identify before granting access.
Did you know?
- You can submit prior authorization requests on our secure provider portal NaviNet, and in some instances receive auto-approval. Turnaround times are faster when using NaviNet.
- In the event you are unable to request a prior authorization, you can request a retro authorization if there is no claim on file. If no claim is on file, UM will review retro requests. Please contact your dedicated Account Executive with questions.
Chronic condition management — blood pressure collection
AmeriHealth Caritas Ohio periodically performs member outreach to complete screening assessments and coordinate care with our members to improve the health outcomes of our members.
When a member measures their blood pressure using a digital in-home monitor during outreach with our care management staff, we will send you a letter summarizing the results. Click to view the summary chart that you will receive.
Reducing disparities in the management of hypertension in African American members
This toolkit covers topics such as barriers to care within the African American population and supportive best practices, tools, and strategies when working to reduce high blood pressure for your African American patient population.
Sign up for this newsletter
Our monthly newsletter, Provider Partnerships, keeps you informed about plan news, updates, and resources. Click here to sign up.
Member rights and responsibilities
AmeriHealth Caritas Ohio members have rights and responsibilities. We believe all members have the right to receive information on the services AmeriHealth Caritas must provide, the right to be treated with respect, dignity, and privacy.
- Members have the right to receive medically necessary treatment options for their conditions no matter the cost or benefit coverage.
- Members are to take part in decisions about their healthcare.
- Members are to treat healthcare staff with respect, be aware of the benefits and services available to them.
- Ask for more explanations if they do not understand their doctors' instructions.
- To provide their physicians with accurate and complete medical information.
Redeterminations
We understand that many members may be unaware that their redetermination period is approaching, and your engagement can play a crucial role in ensuring they take the necessary steps to avoid a lapse in coverage. We encourage our providers to remind their patients that they may need to complete the redetermination process to help ensure they can retain their Medicaid benefits.
Please let us know how we can support you in sharing this important information. We appreciate your partnership and commitment to member health and continuity of care.
Provider resources
We highly recommend providers take a few minutes to familiarize themselves with the tools available on our website. Our user-friendly tools and resources are designed to support Ohio’s Medicaid providers and your staff in giving members excellent and efficient healthcare.
- prior authorization lookup tool
- video tutorials for claims submission
- step-by-step instructions for claims submission and our secure provider portal NaviNet
- Provider Manual
- Provider Claims and Billing Manual
- contact information for our call center and AmeriHealth Caritas Ohio provider services
- monthly CPSE reports and trending claims issue information
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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ODM required annual EPSDT education
AmeriHealth Caritas Ohio provides this Healthchek education to all contracted providers on an annual basis.
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 three.
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.
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Virtual office hours
Got Questions? Let us help you. Join the ACOH Provider Services team for a virtual office hours. Our team will be here to help answer your questions or help you navigate our provider resources. We will be offering virtual office hours with no registration necessary.
Click here to join on any of these dates:
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Tuesday, July 29
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Noon to 1 p.m.
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Utilization Management
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Tuesday, August 26
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Noon to 1 p.m.
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NaviNet
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Friday, September 26
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Noon to 1 p.m.
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Population Health & Care Coordinators
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Provider orientation
Join us for virtual New Provider Orientation sessions. They are an opportunity for us to introduce AmeriHealth Caritas Ohio, how we operate, what tools and opportunities we have available to our providers, and what sets us apart from the other managed care organizations in the state. You can schedule an individual orientation for yourself or your staff with your account executive or attend one of the virtual group sessions.
Tuesday, September 16
10 a.m. - 11 a.m.
Click to register
Your personal AmeriHealth Caritas Ohio Account Executives look forward to meeting you! Click here to see the entire calendar.
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Registration open for the 2025 CMC Summer Learning Session
ODM will once again be hosting an in-person CMC Summer Learning Session for all currently enrolled CMC practices.
Date: August 7
Time: 9 a.m. to 4 p.m.
Where: 4200 Surface Road, Columbus, OH 43228
Room: Willow/Walnut conference room
Space is limited and each attendee must register in advance. Parking is free.
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Comprehensive Primary Care (CPC) quarterly webinar series
The 2025 CPC quarterly webinar series will focus on keeping practices informed about the latest CPC updates, learning opportunities, discussions and more. Topics will be sent out ahead of time. Click here to register.
These take place from 9:30 a.m. to 11 a.m. on the following dates:
- Tuesday, September 16
- Tuesday, November 18
For those who are unable to attend the webinars, the presentations along with a brief description of the covered webinar topics will be posted to the CPC Webinars and Trainings webpage. It is important that all CPC practices attend the webinar sessions, or at a minimum, review the posted presentations. Doing so keeps our practices up to date on all things CPC.
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Cultural competency training opportunities
AmeriHealth Caritas Ohio is committed to promoting education 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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National Minority Mental Health Awareness Month |
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July is Minority Mental Health Awareness Month but reducing health disparities is a year-round priority at CDC. Everyone benefits when people from racial and ethnic minority groups can thrive. We all have a role to play in promoting mental health for people in racial and ethnic minority groups. Share this information with your colleagues and in your communities!
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Healthcare systems have a role to play in improving mental health for people from racial and ethnic minority groups. They can:
- Screen patients for depression and other mental health conditions and refer patients to accessible mental health care services.
- Make mental health educational materials available to all patients during their appointments, via patient portals, and in waiting rooms.
- Ensure mental healthcare services are culturally and linguistically appropriate.
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"Prioritizing Minority Mental Health," CDC,
accessed July 8, 2025. |
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Need help?
AmeriHealth Caritas Ohio Provider Services is ready to help.
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