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📰 Provider Update: Understanding Balanced Billing in Medicaid
As a contracted provider with AmeriHealth Caritas Ohio, it’s essential to understand the rules and responsibilities around balanced billing to ensure compliance and protect our Medicaid members.
🚫 When billing a Medicaid member is not permitted
Providers may not bill Medicaid recipients when a claim is denied due to:
- Unacceptable or untimely claim submission
- Failure to obtain prior authorization
- Retroactive determination by a Peer Review Organization (PRO) that the service was not medically necessary
These denials do not transfer financial responsibility to the member.
✅ When billing may be permitted
A provider may bill a Medicaid recipient in lieu of submitting a claim to the Ohio Department of Medicaid (ODM) only if all of the following conditions are met:
- The provider informs the member that the service is covered by Medicaid and that other providers may offer it at no cost.
- The provider notifies the member in writing—before each date of service—that they will not submit a claim to ODM.
- The member signs a written agreement acknowledging financial responsibility before the service is rendered.
- The service is not a prescription for a controlled substance as defined in Ohio Revised Code §3719.01.
Additionally, non-covered services (including those denied for lack of prior authorization) may be billed to the member only if the written notification and agreement steps above are followed.
💡 Important reminder
Under the Social Security Act, all payments from AmeriHealth Caritas Ohio to participating providers must be accepted as payment in full. Members may not be balance billed for medically necessary covered services under any circumstance.
📌 What this means for you
Balanced billing violations can result in compliance actions and member grievances. Please ensure your billing practices align with ODM and AmeriHealth Caritas Ohio policies. If you have questions, contact your Provider Relations representative.
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Redetermination
We understand that 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.
New for 2026 - value-added services and incentives
Contact lenses
Starting 1/1/26 members will be eligible for an allowance up to $150 for contact lenses per calendar year. To qualify for the $150 allowance, members must get an exam, lens fitting and receive a prescription for contact lenses. Members may be responsible for expenses above the benefit allowance in the absence of medical necessity. For more information on conditions where contacts may be medically necessary, please review the policy on Therapeutic Contact Lenses, which can be found on the AmeriHealth Caritas Ohio Provider Portal. Additional information will be posted on the website prior to the new benefit year.
Additional updates
- Asthma bundle for members under 18 with a diagnosis of asthma to support a healthy home environment
- $25 CARE Card benefit for flu vaccination
- $30 CARE Card benefit for pediatric members with two or more antipsychotic prescriptions completing blood glucose and cholesterol testing
- $30 CARE Card benefit for well-child visits age 0-15 months. This is an increase from $20 per visit.
Doula Report of Pregnancy
On October 1, doulas began submitting an electronic Report of Pregnancy (ROP) via the Nurture Ohio system for reimbursement. The ROP serves as the notification to MCO’s and promotes initiation of timely healthcare and connection to prenatal care. A payment of $30 may be made for an ROP that is submitted per member, per pregnancy. For additional information, please see our
Report of Pregnancy (ROP) Submissions Instructions.
Bringing healthcare home to our members
We are excited to announce we now partner with Total Care Connect (TCC) to bring quality, in-home healthcare directly to our members at no cost.
Our dedicated care coordination team works closely with TCC’s team to make these in-home services available:
- Well-child visits
- Annual adult wellness visits
- Pregnancy risk assessment
- Colorectal cancer screening
- Behavioral health screenings
- And more!
To learn more, call our Rapid Response team at 1-833-464-7768 or click here.
In addition, AmeriHealth Caritas Ohio’s Mobile Wellness and Opportunity Center has also partnered with TCC to offer community-based events across the State of Ohio while trying to meet the needs of our members. If you have any questions, please reach out via our Rapid Response team at 1-833-464-7768 or click here.
Are you getting credit for all your closed gaps for multiyear measures?
Multiyear measures include breast cancer screening, colorectal screening, and cervical cancer screening. Did you know if your patient was under a different health plan in previous years, we may not have access to that data which means you have gaps that are closed but you are not getting credit for them? We don’t think this is fair to you and are offering you two options to close these gaps, so you are credited for your efforts!
- Pull the medical record documentation that shows this gap has been closed; be sure it is legible and includes member name, DOB, service date, and is part of their permanent medical record.
- Submit documentation via email at OHQuality@amerihealthcaritasoh.com or fax to 1-833-533-2964.
- Our team at AmeriHealth Caritas Ohio will review your submission and close the gap so long as it meets the requirements in #1.
Cervical cancer screening gaps in care closure support
We want to support you in efforts to increase your cervical cancer screening (CCS) compliance rate. We have identified an opportunity with BD Onclarity™ to offer the HPV Self-Collection Test Kits. It’s the first FDA-approved test for both HPV self-collection and extended genotyping.
For more information and to be connected with the BD Onclarity representative, contact your AmeriHealth Caritas Ohio Account Executive.
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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. Call 1-800-686-1516 or email IHD@medicaid.ohio.gov.
Provider education & training resources
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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Questions about reimbursement or payment policies?
Click the appropriate link below for more detailed information.
Clinical Policies
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.
Electronic funds transfer
AmeriHealth Caritas Ohio has contracted with Change Healthcare and ECHO® Health, Inc., to administer electronic funds transfer (EFT) payments. There are no fees for single payer agreements to receive a direct payment from AmeriHealth Caritas Ohio via EFT or to receive an electronic remittance advice (ERA). Click to learn how to enroll, the payment schedule, and more.
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.
Dispute or appeal?
If a provider disagrees with the outcome of a claim, the first step should always be to submit a claim dispute.
Provider disputes
Provider claim disputes are any provider inquiries or requests for reconsiderations, ranging from general questions about a claim to a provider disagreeing with a claim denial. Provider Dispute Submission Form (PDF)
A dispute can be submitted using any of the following methods:
- NaviNet (recommended method): Providers can submit a dispute with attachments to AmeriHealth Caritas Ohio via NaviNet instead of faxing or mailing. Log in, go to Forms & Dashboards, scroll down to Provider Disputes, click the Submit Provider Disputes link. The turnaround time is 15 days for disputes.
- Mail the form with your supporting documentation to:
AmeriHealth Caritas Ohio
Attn: Provider Claim Inquiry
P.O. Box 7126
London, KY 40742
- Phone: 1-833-644-6001. Select the prompts for the correct department and then select the prompt for claim issues.
- Fax: 1-833-216-2272
Provider appeals
Providers may file an appeal on a denied pre-service within 30 days of the notice of Adverse Benefit Determination (ABD). Provider Appeal Form (PDF)
- Mail the form with your supporting documentation to:
AmeriHealth Caritas Ohio
Attn: Provider Claim Inquiry
P.O. Box 7400
London, KY 40742
- Fax: 1-833-564-1329
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.
Questions
If you have questions, please contact your Provider Account Executive or the Provider Services department at 1-833-644-6001.
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 Prior authorizations |
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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.
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 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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Medicaid’s Office of Behavioral Health Policy updates provider resources
Updated information has been posted to the Ohio Department of Medicaid website. The Behavioral Health Provider Manual (BH Manual) version 1.28, has updated content and clarifications.
Ohio Medicaid’s BH Coding Workbook also has been updated to reflect changes from the BH Manual.
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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 Resources and reminders |
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2025 Provider Satisfaction Survey
A satisfaction survey was mailed by our partners at Qualtrics to randomly selected providers for their anonymous feedback. AmeriHealth Caritas Ohio will use your feedback to help direct administrative and operational changes to our health plan and highlight areas of improvement. Your experience is valuable to us, and we appreciate your feedback and ongoing commitment to our members.
PCP change form
Do you have a patient whose Member ID card does not have you listed as their assigned PCP? You can use this PCP change form to request the members PCP be changed. Access the form here.
New vendor to provide in-home health evaluations (IHE)
AmeriHealth Caritas Ohio works with you to collect complete and accurate member health histories to help facilitate care management, as appropriate. We are partnering with Signify Health to conduct In-Home Health Evaluation (IHE) visits to assist us in documenting our member's/your patient’s healthcare conditions, diseases and other social demographic related factors. Read all of the details here.
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.
HEDIS guidelines for the Care Gap Closure program
The HEDIS 2025 Documentation and Coding Guidelines for care delivered in 2025 can be viewed at NaviNet.
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 Training opportunities |
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Virtual office hours
Got Questions? Let us help you. Join the AmeriHealth Caritas Ohio Provider Services team for a virtual office hour. Our team will be here to help answer your questions or help you navigate our provider resources. No registration is necessary. Just click here to join on any of these dates:
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Fri., Oct. 24
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Noon to 1 p.m.
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Medicaid Renewal and Redetermination
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Tues., Nov. 12
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Noon to 1 p.m.
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Quality
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Tues., Dec. 16
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Noon to 1 p.m.
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Value-Based Reimbursement
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Provider orientation
AmeriHealth Caritas Ohio invites you and your staff to join us for a virtual New Provider Orientation session.
Tuesday, Nov. 18
10-11 a.m.
Click to register
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All-MCO doula technical assistance trainings
Ohio's seven Medicaid Managed Care Organizations (MCOs), in partnership with the Ohio Department of Medicaid, are hosting virtual technical assistance training for doulas.
- Training session 2: Nov. 3, from 2 to 3:30 p.m.
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Each managed care plan has created a video about working with doulas. You can view AmeriHealth Caritas Ohio's video on YouTube here. |
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Comprehensive Primary Care quarterly webinar series
The final webinar of 2025 will take place on Tuesday, Nov. 18 from 9:30 to 11 a.m. The 2025 Comprehensive Primary Care (CPC) webinar series focuses 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.
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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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Tell us a little bit about where you’re from and where you went to school.
My name is Yvette Harris and I am a proud graduate of Robert S. Rogers High School.
What drew you to this profession?
My career in Medicaid started in the late '90s when I became one of the first Medicaid reps at Paramount Advantage. Managed care was new to the area, and my position was enrolling and educating potential members. The job was especially important to me because I knew without this healthcare information big mistakes could happen. With this type of employment, I was able to help young mothers that lived next door in the same low-income housing complex as well as those in comparable sites throughout the city. I was relatable and the women would listen because I lived in the same environment. I wanted these ladies to understand the necessity of knowing that their healthcare provider accepted the new Managed Care Plan (MCP), what a MCP was, and how to disenroll from the plan if needed. This education became my passion and almost 30 years later, I
Me on the mic |
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am the last one of those reps, still educating and helping the community.
What do you like to do in your free time?
In my free time, I am a grandmother to four and a great grandmother to one.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
If I could have dinner with anyone, it would be my mother. She transitioned last year and I miss her so much.
Any interesting facts about yourself that you’d like to share?
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I am a motorcycle enthusiast and at one time I was the president of our motorcycle club and now I have a trophy-winning Slingshot!
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I have three fur kids.
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I am a radio personality on Mix 95.7 in Toledo, hosting the
Saturday Morning Blues Party.
Slingshot trophy |
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What is Breast Cancer Awareness Month?
Breast Cancer Awareness Month (BCAM) is a global campaign to raise awareness for breast cancer, increase screenings, and provide critical support for patients and survivors.
Breast cancer death rates in the United States have dropped by 44% since 1989. That’s not a coincidence. For 40 years, BCAM has helped raise awareness of breast cancer across the nation. It has encouraged millions to take action, resulting in increased early detection and advancements in treatment that have saved more than half a million lives.
Free resources: https://www.nationalbreastcancer.org/bcam-resources/
Did you know AmeriHealth Caritas Ohio offers preventive mammogram breast cancer and cervical cancer screenings? Our list of benefits can be viewed here.
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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.
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Need help?
AmeriHealth Caritas Ohio Provider Services is ready to help.
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