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Redetermination
We understand that members may be unaware that their redetermination period is approaching. 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:
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- Well-child visits
- Annual adult wellness visits
- Pregnancy risk assessment
- Colorectal cancer screening
- Behavioral health screenings
- And more!
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To learn more, please contact Member Services toll-free at 1-833-764-7700 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 to Member Services at 1-833-764-7700 or click here. |
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Virtual autism assessments
AmeriHealth Caritas Ohio has partnered with the Zest Pediatric Network to offer virtual autism evaluations from specially trained pediatricians using standardized assessment tools. This will allow AmeriHealth Caritas Ohio members throughout the state to get appointments within weeks instead of months and complete the assessments from the comfort of their own homes. If the child is between 18 months and 11 years old and has shown signs of a developmental delay or autism spectrum disorder, or is currently on a waitlist for evaluation, the Zest Pediatric Network will help with the next steps. More information can be found here.
Encourage patients to get flu and RSV vaccines
As we move further into flu and respiratory virus season, we are aware that guidance on vaccines may vary and of the potential for confusion. We encourage members to discuss any questions or concerns they may have with you, their primary care provider, to help determine what’s right for them.
We recognize that some members may face barriers to getting vaccinations. Please remind them that:
- There is no cost to receive these vaccines.
- Translation and interpreter services are available to support patients in their preferred language.
Your recommendation matters and is one of the stronger factors in a member’s
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decision to get vaccinated. Please take a moment to discuss the benefits of flu and RSV vaccines during this flu season. For up-to-date information, visit vaccine recommendations or Advisory Committee on Immunization Practices (ACIP).
Thank you for your ongoing efforts to keep our communities healthy.
Supplemental data options for providers
Elevate your practice by harnessing the power of data sharing—unlock real-time insights, streamline workflows, and drive measurable improvements in patient care. Choose the supplemental data solution that best fits your organization and experience the transformative impact on quality and efficiency. Take the next step today to optimize outcomes for your patients and your team. Click here to learn more about your options!
Pre-visit planning for better care
Pre-visit planning isn’t just preparation; it’s a proven method to enhance patient outcomes and streamline provider workflows. By proactively using Scorecards and creating tailored checklists for each visit, teams can close care gaps and reduce missed opportunities to improve patient experience. Make every visit count by exploring our Provider Pre-Visit Educational PowerPoint for actionable tips and tools. To learn more, click here.
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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 and 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.
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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
Claim attachments
Step 1: Go to Availity attachment portal, send the attachments first. Make sure the “Attachment Control #” is unique to that claim and make note of it. For example, if they are sending three attachments then, Attachment A – 111111, Attachment B – 22222, …
Step 2: Go to Change Healthcare's portal, ConnectCenter. When keying in the claim, in the attachment section, add the “Attachment Control #” which they noted (111111, 222222, ...). And from the drop-down menu choose the right “Attachment type.”
Note: “Attachment Control #” must be unique for that claim. You can add Member name or anything, but it must be unique for that claim. In other words, you can use 111111, 222222, … for the second claim you are submitting.
NaviNet pro tips
Claims Investigations
- If a provider has multiple offices or TINs, users must be linked to each TIN for the corresponding office to view claims and remittance advice.
- In a claims investigation, only certain documents are permitted to be uploaded to the investigation function. If the document type is not listed below, a dispute must be filed, and the document should be attached with the dispute.
- EOBs should not be uploaded for COB when a claim denies for “EOB from primary payer required.” Please send a corrected claim or file a dispute. EOBs for non-covered or exhausted benefits letters are permitted to be uploaded in the investigation.
How to file a Dispute in NaviNet
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).
- 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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📰 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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 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 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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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.
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 identity 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.
Tuesday, Dec. 16
Noon to 1 p.m.
Value-based Reimbursement |
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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.
I’m originally from Cincinnati but currently live and work in Columbus. I attended Miami University in Oxford, Ohio, where I studied English Creative Writing and Mass Communications.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?
I joined AmeriHealth Caritas Ohio because I wanted to be part of a mission-driven organization that puts people first. I saw an opportunity to make a meaningful impact on Medicaid members’ lives, especially through quality improvement initiatives that address real barriers to care by being at the forefront of best in practice process and policy development.
What drew you to this profession?
I’ve always been passionate about healthcare and improving systems that serve vulnerable populations. Quality management allows me to combine data-driven strategies with my creativity to create compassionate care, helping ensure that every member receives the support they need.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
That’s a tough one. I love the idea of a banquet dinner with all my forefathers. Of course, I would want to start with my father and grandfather, both of whom I miss dearly. I would thank them for the amazing life I had and make sure they know how grateful I am. Then I would like to hear stories |
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from those I didn’t know. Their perspective, resilience, and leadership in life have always inspired me, and I’d welcome the chance to learn first-hand from their experiences.
What do you like to do in your free time?
In my free time, I enjoy spending time with family traveling to different destinations while collecting memories along the way. It helps me recharge and stay grounded.
What are 2 apps on your phone you CANNOT live without?
YouTube and iMessage. I’ve learned most things later in life by attending YouTube University and couldn’t imagine life without the video content at my fingertips. iMessage because I have to stay in contact with my family. Not sure I need to “talk” to them every day, but never communicating with them would be tragic.
Any interesting facts about yourself that you’d like to share?
I am a member of Kappa Alpha Psi Fraternity, Inc. where my great-grandfather was the 12th Grand Polemarch (National President) during our early development.
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Did you know AmeriHealth Caritas Ohio members with diabetes can join a special program to help them manage their condition? AmeriHealth Caritas Ohio partners with Pulsewrx to provide members living with diabetes with mobile smartphones. Apps and tools on the phone will support continuous glucose monitoring so members with diabetes can have easier control of their blood sugar levels.
Any healthcare provider, or the member, can call Member Services at 1-833-764-7700 (TTY 1-833-889-6446), 24 hours a day, seven days a week, to get the member enrolled in the diabetes program. Members can also log in to the member portal and go to Enroll in a Special Program. For more information, visit our Special Health Programs webpage. |
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Beware of phishing scams — don’t take the bait!
One of the biggest information security risks in healthcare settings occurs when someone in a provider's office opens a phishing e-mail and clicks on a malicious link. It only takes one click to compromise a practice's data security.
Why it’s important
Phishing scams are emails that look real but are designed to steal important information. A phishing email with malicious software can allow cybercriminals to take control of your computer and put protected health information (PHI) and personally identifiable information (PII), as well as a practice’s confidential and proprietary information, at risk.
It may be a phishing email if it:
- Promises something of value (e.g., “Win a free gift card!”).
- Asks for money or donations.
- Comes from a sender or company you don’t recognize.
- Links to a site that is different from that of the company the sender claims to represent.
- Asks you for personal information, such as your username and password/passphrase.
- Includes misspelled words in the site’s URL or subject line.
- Has a sense of urgency for you to act now.
Phishing emails may come from a trusted business partner that has experienced a security incident. All emails from outside your practice should be scrutinized.
If you suspect an email may be phishing, here’s what you should do:
- Do not click any links in the email.
- Do not provide your username and password. You should never share your username or password, even if you recognize the source. Phishing scams frequently mimic well-known companies such as banks or retailers like Amazon.
- Do not reply to the email or forward it to anyone else at your organization.
- Familiarize yourself with your practice’s process for reporting suspicious emails. If you suspect an email is a phishing attempt, report it immediately.
- If you have questions, please contact your practice’s security department.
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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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