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Important reminder regarding automated calls
AmeriHealth Caritas Ohio does not disclose claim information to automated or AI‑generated callers. Providers calling about denied claims and other claim inquiries, must contact us using a live representative. To receive assistance, AmeriHealth Caritas Ohio Provider Services can be reached at 1-833-644-6001.
By ensuring that claims inquiries are handled by live representatives, we can provide more accurate and personalized assistance to our providers. This approach will not only enhance the quality of support we offer but also streamline the process, leading to quicker resolutions and better outcomes for everyone involved.
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Doula certification renewal
The Ohio Board of Nursing’s 2026 renewal period for State of Ohio Certified Doulas is open and closes March 31. All renewals after March 2 through March 31 will include a $50 late fee.
Doulas are required to renew their certification every two years during even-numbered years. If you do not renew before the March 31 deadline, your certificate will lapse on April 1, and you will no longer be able to practice as a State of Ohio Certified Doula or be eligible for Medicaid reimbursement.
Please note that if you become a doula between renewal periods (the timeframe is defined as April 1 of any even year through December 31 of the following odd year), you are still required to renew your certification when a new season begins.
To renew, log into your Ohio eLicense account and submit the renewal application along with the $35 renewal fee. Please note: the State of Ohio applies a $3.50 transaction fee to all payments.
For more details about renewals and fees, please visit https://nursing.ohio.gov/state-of-ohio-certified-doulas. |
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Quality Counts – The HEDIS Brief
Starting this month, AmeriHealth Caritas Ohio will provide you with monthly videos that are all 3 minutes or less, focusing on HEDIS Metrics and practical ways to close gaps in care. Let’s make this year one of progress and partnership in quality care!
This month’s
HEDIS Brief – Quality Counts! spotlights:
- Adults’ Access to Preventive/Ambulatory Health Services (AAP)
- Cervical Cancer Screening (CCS)
- Controlling Blood Pressure
- Statin Therapy for Patients with Cardiovascular Disease — Received and Adhered
- Statin Therapy for Patients with Diabetes — Received and Adhered
- Timeliness of Prenatal and Postpartum Care (PPC)
You can visit these videos anytime on our website to refresh your knowledge. Have a topic you’d like us to cover? Reach out to your Account Executive—we’re here to help!
We look forward to partnering with you throughout 2026 as we work together to advance quality care. |
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New 2026 benefit: contact lens allowance
AmeriHealth Caritas Ohio members will have access to a new Value-added Service: Up to $150 toward the purchase of contact lenses each calendar year.
To qualify, members must:
- Complete an eye exam
- Receive contact lens fitting
- Have a valid contact lens prescription
What Providers Need to Know:
Please ensure members receive the required eye exam and fitting, and that prescriptions are current and documented. This will help members take full advantage of their new benefit and keep their vision clear and healthy!
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HEDIS records request
HEDIS® is a national set of quality measures that helps health plans and providers understand how well members are receiving important care and services. State and federal agencies use HEDIS results to monitor quality, support accreditation, and compare performance across health plans. The information collected each year also helps identify opportunities to improve care for the communities we jointly serve.
Each year from January through April, AmeriHealth Caritas Ohio conducts medical record reviews for a small group of members whose claims data show
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missing information or possible care gaps. During this time, you may receive requests for medical records needed to complete this review.
To support this year’s process, AmeriHealth Caritas Ohio has partnered with PalmQuest, who will coordinate the medical record retrieval on our behalf.
We sincerely appreciate your partnership and your timely assistance in responding to these requests. Your support helps ensure accurate quality reporting and better outcomes for our members.
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Ohio Department of Medicaid (ODM) updates
To stay up to date on ODM news, subscribe to the ODM Press.
Orthodontic Evaluation Form 03630 update
- The Ohio Department of Medicaid revised Form 03630 in September 2025 for a January 1, 2026, effective date. The “Revised ODM Form 03630” replaces all previously existing versions of Form 03630 and their included criteria.
- The new Ortho process went into effect January 1 and will be REQUIRED on all cases submitted moving forward.
- The updated form can be accessed directly from the ODM website: ODM 03630 - Referral Evaluation Criteria for Comprehensive Orthodontic Treatment
Billing codes
ODM has provided guidance on billing codes for multiple births through Medicaid Advisory Letter (MAL) No. 685. This MAL can be found here.
With the new integrated Ohio Medicaid Enterprise System (OMES), delivery codes for multiple births should be reported on separate details on the claim with modifier 51 appended.
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
Comprehensive Payment Systems Errors Report
The Ohio Department of Medicaid’s Comprehensive Payment Systems Errors (CPSE) report is updated on the first Tuesday of every month to provide Next Generation program providers with updates on the status of resolution of issues they may be experiencing when submitting claims or accessing information from the Ohio Medicaid Enterprise System.
Providers experiencing issues can check the CPSE report to see if their issue is a known issue being addressed. If the issue is not included in the report, providers should contact the ODM Integrated Helpdesk (IHD) at 1-800-686-1516 to report their issue. Issues reported through the IHD are documented, a ticket number assigned and tracked through ServiceNow by ODM. The resolution status of issues identified as defects can be found in the CPSE report. IHD representatives can also provide updates on issue resolution status.
For a list of resolved issues previously tracked in the CPSE report, please see this document.
The Claims Payment Systemic Errors (CPSE) report is updated and posted monthly on our website.
Electronic claims submission
Providers can choose the submission option that works for them. It can be any approved clearinghouse or direct to ODM. Preferred options are:
- Availity (subscription)
- Change Healthcare (no cost)
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.
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.
NaviNet Improvement
NaviNet has implemented improvements allowing providers to view the status of a dispute, appeal, or complaint as well as a copy of the determination letter.
The process to submit a dispute or appeal will not be changing, but this feature will be available through the forms and dashboards page, under the name check claim dispute or complaint status. The status page will have its own search fields which require the Payee ID (the ID of the provider or group the claim is being paid to, commonly found in box 33 of the CMS 1500 form) as well as one of the following. The Claim ID, Member ID, or Submission Date Range.
New to NaviNet?
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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Prior authorization removal effective Jan. 1
As of January 1, prior authorization for the HCPCS codes and services listed in the table do not require prior authorization for in-network or out-of-network providers.
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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Upcoming changes to eligibility for OhioRISE members
The Ohio Department of Medicaid intends to amend the OhioRISE: eligibility and enrollment rule, 5160-59-02, so that enrollment in OhioRISE will become effective the first day of the calendar month of eligibility. This change is being made to align with managed care program enrollment and to reduce manual retro-enrollments due to an inpatient behavioral health admission. The rule change is intended to be effective July 1.
Clarification of financial responsibility for behavioral health services provided to children and youth is found in the OhioRISE Mixed Services Protocol (Protocol). Managed care plans will still be responsible for CANS assessments completed prior to OhioRISE enrollment. The Protocol will be updated as needed to support the rule change.
This change in retro eligibility to the first day of calendar month that a member becomes eligible for OhioRISE may cause behavioral health claims that paid to be taken back so that the claim can be resubmitted to the OhioRISE plan for processing.
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Billing reminder - rendering practitioners/affiliation
ODM requires that the rendering practitioner for behavioral health services be listed on claims submitted to Ohio Medicaid for payment. Their personal National Provider Identifier (NPI) must be reported in the rendering field on the claim for each service they provide. All rendering practitioners are required to have an NPI to render services to Medicaid enrollees AND they will be required to enroll in the Ohio Medicaid program and affiliate with their employing/contracting agency. Information about obtaining an NPI is available at: https://nppes.cms.hhs.gov/login. Once the rendering practitioner has obtained an NPI, they must enroll as a provider in the Ohio Medicaid Program via the Provider Network Management (PNM) portal. More details on this process are available at: https://managedcare.medicaid.ohio.gov/managed-care/centralized-credentialing/about-pnm.
CEU opportunities
Sign up to receive notifications of FREE CEU trainings provided by AmeriHealth Caritas of Ohio and approved by the Counselor, Social Work and Marriage and Family Therapist Board (CSWMFT).
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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Free CEU opportunities from AmeriHealth Caritas Ohio
- Engage, Empower, Treat: A Behavioral Health ECHO Learning Series (Feb.-July) AmeriHealth Caritas Ohio, in collaboration with Project ECHO, is excited to launch an emerging case-based learning model for practitioners.
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Date
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ECHO Learning Series Topics
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March 12
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Reframing Addiction: A Chronic Disease Approach to Treatment and Recovery
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April 9
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Zero Suicide using the Trauma Informed Care Model
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May 14
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Managing Behavioral Health Conditions During the Perinatal Period
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June 11
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Attention Deficit Hyperactivity Disorder (ADHD) in Adults
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July 9
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Start the Conversation: Assessment and Intervention for Alcohol Use
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Additional free CEU opportunities |
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Virtual provider orientation
AmeriHealth Caritas Ohio invites you and your staff to join us for a virtual New Provider Orientation session. Click here to see the calendar.
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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 was born and raised in Cleveland and currently live in Cincinnati. I attended The University of Akron School of Social Work, where I earned my Bachelor of Arts in Social Work (BASW) and a certification in aging services. Go Browns! Go Zips!
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?
I joined the team at AmeirHealth Caritas Ohio because I saw an opportunity for me to continue the work of serving the community in a meaningful way. I’m proud to represent a plan supported by collaborative, forward thinking teammates who value innovation and are committed to improving health outcomes for our members and the communities we serve.
What drew you to this profession?
Being a Community Health Educator on the Ohio outreach team aligns closely with my background in social work and my passion for service. Knowing the Sisters of Mercy shaped a community impact mission over 40 years ago, while centering care for members, is both powerful and inspiring.
What do you like to do in your free time?
I
enjoy spending time with my two greatest joys, my grandchildren, Zeke and Zara. Much of my recent free time has been dedicated to renovating our 140-year-old home. I’m also actively involved in local community councils and non-profit boards. I love cooking, traveling, kayaking, and staying connected to my community.
 My 2 GRAND loves! |
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If you could have dinner with anyone in the world, dead or alive, who would it be? Why?
I would choose Harriet Tubman to have dinner with to hear firsthand how she managed to keep unwavering commitment to freedom, justice, and service – under constant
threat to her life. She reshaped America’s history and continues to inspire the fight for equality today.
What are 2 apps on your phone you CANNOT live without?
T
he Cleveland Browns app is my go-to source for staying in step with every roster move, update and Dawg Pound moment.
I also rely on the Tasty app – what once was my love for reading cookbooks has turned into discovering and sharing great meals with friends and family through technology.
Any interesting facts about yourself that you’d like to share?
I am a proud two-time Passion In Work flower winning employee and am a devoted Browns fan despite how painful that loyalty can be.
I’ve also been a member of Alpha Kappa Alpha Sorority, Incorporated since 1987, an organization rooted in sisterhood, service, and community impact.
Jill Gorley, LSW
Community Health Educator, Sr.
(Hamilton, Scioto, Warren, Clermont, Clinton, Brown, Highland, Adams, Pike Counties)
jgorley@amerihealthcaritasoh.com
1-513-635-7331
My sad CLE Browns face |
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February is American Heart Month, a dedicated time to raise awareness about cardiovascular health, the leading cause of death in the U.S. The month encourages everyone, especially women, to focus on heart-healthy lifestyles, understand risk factors, and take action to prevent heart disease.
Key aspects of American Heart Month:
- Purpose: To urge individuals to manage blood pressure, reduce cholesterol, and adopt healthier diets to combat heart disease.
- Color & Symbol: The color associated with this awareness month is red. National Wear Red Day, celebrated on the first Friday in February, encourages wearing red to raise awareness, particularly about women and heart disease.
- Key Messages & Actions:
- Know Your Risks: Monitor blood pressure, cholesterol, and blood sugar levels.
- Lifestyle Changes: Adopt a heart-healthy diet, increase physical activity, and avoid smoking.
- Lifesaving Skills: Learn CPR to help in emergencies, such as cardiac arrest.
- Focus Areas: The campaign often highlights specific themes, such as #HealthyHeartsForAll, which focuses on empowering individuals with mobility disabilities to manage their heart health.
DYK
More than 23,000 children experience cardiac arrest outside of the hospital each year? Learn CPR today so you can be ready and become a part of the Nation of Lifesavers. Because no one, especially our most precious ones, should face a life-changing moment alone.
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This Black History Month, we honor the incredible contributions of Black medical pioneers who have shaped healthcare and inspired generations. Their achievement reminds us of the importance of resilience, innovation, and equity in advancing health for all.
- Rebecca Lee Crumpler (1831–1895): The first Black woman in the United States to earn a medical degree, Dr. Crumpler devoted her career to underserved communities, particularly freed slaves after the Civil War. Her groundbreaking work challenged the norms of her time and set a precedent for inclusive care.
- Charles R. Drew (1904–1950): Renowned as the “father of the blood bank,” Dr. Drew developed methods for blood storage and transfusion that revolutionized medicine. His innovations saved countless lives during World War II and laid the groundwork for modern blood donation practices.
These trailblazers remind us of the brilliance and perseverance of Black healthcare professionals who overcame immense challenges to improve care for all.
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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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