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Provider update
While the Centers for Medicare & Medicaid Services regulations allow up to 72 hours to issue an expedited authorization decision, our current process remains the same. In accordance with Ohio Administrative Code Rule 5160‑26‑03.1, expedited requests are reviewed and decisions are communicated as quickly as the member’s health condition requires, and no later than 48 hours from receipt of the request. |
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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.
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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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Timely reminder
AmeriHealth Caritas Ohio requires that all provider claims, resubmissions, corrected claims, and disputes be submitted within established timely filing limits. Claims or claim-related submissions received outside of these timeframes will be denied for Timely Filing (TFO) and are not eligible for reconsideration unless otherwise required by contract or regulation.
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Definition
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Time Frame
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Exceptions /Limitations
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Rejected Claims
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Are defined as claims with invalid or required missing data elements, such as the provider tax identification number, Provider Medicaid ID number, member ID number, that are returned to the designated EDI1 source without registration in the claim processing system.
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Par/Non Par Outpatient: 365 days from the begin date of service
Par/Non Par Inpatient: 365 days from the discharge date of service
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COB: 180 days from the date of the EOB
EXCEPTIONS:
Claims denied by the primary for Timely Filing will stay denied TFO
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Initial Claim
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A first-time submission on a UB04 or CMS1500 for services rendered to a member
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Par/Non Par Outpatient: 365 days from the begin date of service
Par/Non Par Inpatient: 365 days from the discharge date of service
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COB: 180 days from the date of the EOB
EXCEPTIONS:
Claims denied by the primary for Timely Filing will stay denied TFO
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Resubmission of a Claim
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A "Resubmission" is defined as a claim originally denied/rejected because of missing documentation, incorrect coding, etc., which is now being resubmitted with the required information.
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Par/Non Par Outpatient: 365 days from the begin date of service
Par/Non Par Inpatient: 365 days from the discharge date of service
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Recovered claim: 30 days from the date of the recovery
COB: 180 days from the date of the EOB
EXCEPTIONS:
Claims denied by the primary for Timely Filing will stay denied TFO
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Corrected Claims
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A corrected claim is a replacement of a previously billed claim that requires a revision to coding, service dates, billed amounts or member information. Must Follow corrected claims billing requirements (Frequency code of 7 and Original Claim ID in Box 22 of the CMS 1500 and Box 64 (A,B,C) of the UB04)
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Par/Non Par Outpatient: 180 from the date of denial/recovery or 365 days from the begin date of service
Par/Non Par Inpatient: 180 from the date of denial/recovery or 365 days from the end date of service
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Recovered claim: 30 days from the date of the recovery
COB: 180 days from the date of the EOB
EXCEPTIONS:
Claims denied by the primary for Timely Filing will stay denied TFO
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Dispute
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A provider’s disagreement with the way a claim has processed/denied
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Par/Non Par Outpatient: 365 days from the begin date of service or 60 days from the date of denial/resolution.
Par/Non Par Inpatient: 365 days from the discharge date of service or 60 days from the date of denial/resolution.
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Recovery Dispute
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A provider’s disagreement with a claim recovery project (ACOH has sent a letter).
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30 days from the date of the notification
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Any provisions, exclusions or limitations outlined within contractual language
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Account Executive Escalations
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A provider contacting their account executive to escalate mishandled disputes/claims.
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60 days from the date of denial, payment, or determination letter
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Claim reconsiderations with dates of service (DOS) beyond 730 days cannot be considered for review for any reason.
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📰 Understanding balance billing in Medicaid
As a contracted provider with AmeriHealth Caritas Ohio, it’s essential to understand the rules and responsibilities around balance 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
Balance 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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Ohio Department of Medicaid (ODM) updates
To stay up to date on ODM news, subscribe to the ODM Press.
Important reminder: Update 1099 address information in the Provider Network Management module
It is important that providers update all 1099 address information in the PNM module, including extra address details like suite number, house/office number, etc. to reduce the chance of non-delivery by the postal service.
ODM issues 1099-MISC to all healthcare providers that receive payment exceeding $600 for the tax calendar year (2024). These forms are mailed and copies can be accessed through the PNM module for self-service download. To take advantage of self-service access to 1099 information via the PNM module please review the Quick Reference Guide on Accessing the 1099. Another tool, the Quick Reference Guide for Updating or Adding Practice Locations, provides basic steps for updating any address including the 1099 address. Links to both are below:
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.
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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
NaviNet® Vision Accumulator Enhancement
Vision providers can now view whether a member has used their vision benefits for the current benefit year by accessing the Vision Accumulator within the NaviNet Provider Portal.
Once logged into NaviNet, providers will select the
Eligibility and Benefits Inquiry link under
Workflows for this Plan.
Search by one of the following data elements:
- Member ID
- Member name and date of birth
The search will return the Eligibility and Benefits screen which will display a Patient Alert Details popup. The Patient Alert popup will include an option for Vision Accumulator. Selecting the Vision Accumulator link will open another screen which displays:
- Eye Exam Visit Count
- Frame and Lens, including Allowance, Used and Balance, (if applicable)
- Frame Visit Count
- Lens Visit Count
- Contact Lens Visit Count
NaviNet® Disputes Status Enhancement
This enhancement is designed to streamline your workflow by eliminating the need to call the health plan to check whether a member has used their vision benefits for the current benefit year prior to scheduling their eye exam.
Providers can now view the status and a copy of the determination letter for previously submitted disputes via the NaviNet provider portal by accessing Forms and Dashboards and selecting the Check Dispute Status link.
Search by one of the following data elements:
- Claim ID
- Member's ID
- Submission Date Range - Begin Date and End Date
Providers will be able to view 18 months of status history based on the dispute receive date.
The search will return one of the following statuses:
In Progress, Overturned, Upheld or Voided and will include the date the determination letter was uploaded into the system. A copy of the determination letter will be available under Practice Documents.
This enhancement is designed to streamline your workflow by eliminating the need to:
- Call the health plan to obtain the status of your request.
- Wait to receive the determination letter by mail.
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.
How to Register for NaviNet
NaviNet is an easy-to-use, no-cost, web-based platform that links providers to AmeriHealth Caritas Ohio. Through NaviNet, you can access and submit:
- Real-time clinical Healthcare Effectiveness Data and Information Set (HEDIS) alerts
- Eligibility information
- Claims information and updates
- Benefits information
- Prior authorizations
NaviNet provides a quick and streamlined registration process using our digital documentation system for automated identity and business verification. When registering for NaviNet, please have the following information ready to be entered into the online registration form:
- Office name
- Address
- Phone number
- TIN
You will also be asked to attach one of the following documents for verification:
- Certificate of Good Standing
- Sole Proprietor SS-4
- IRS 147C Letter
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 changes effective Jan. 1
As of January 1, prior authorization for the HCPCS codes and services listed in the table do/do not require prior authorization for in-network or out-of-network providers.
Helpful prior authorization information
The most up-to-date list of services requiring prior authorization can be found on our website. The Plan’s Utilization Management (UM) department hours of operation are 8:30 a.m. to 5:00 p.m. ET, Monday through Friday except for holidays. The UM department can be reached at:
- Utilization Management telephone: 1-833-735-7700
- Utilization Management prior authorization fax: 1-833-329-6411
For prior authorizations after hours, weekends and holidays, call Member Services at 1-833-764-7700 (TTY 1-833-889-6446, 24 hours a day, seven days a week.
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
How to submit prior authorization
Behavioral health prior authorizations
Common electronic prior authorization errors
Medical necessity
Pharmacy prior authorizations
Physical health prior authorizations
Physician-administered medication prior authorization request form (PDF)
Standard and expedited benefit determinations
Prior Authorization Lookup Tool
To find out if a service needs prior authorization, type a Current Procedural Terminology (CPT) code or a Healthcare Common Procedure Coding System (HCPCS) code into the tool.
Important notice
This tool provides general information for outpatient services performed by a participating provider. Prior authorization requirements also apply to secondary coverage.
The following services always require prior authorization:
- Inpatient services (elective and urgent)
- Services with a non-participating provider — join our network
- Codes not on the Ohio Medicaid Fee Schedule
If you have questions about this tool, a service, or to request a prior authorization, contact Utilization Management at 1-833-644-6001.
Did you know?
- You can submit prior authorization requests electronically 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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Quality Counts – The HEDIS Brief
Our HEDIS Brief is a series of training videos about the Healthcare Effectiveness Data and Information Set (HEDIS). Each video is three minutes or less, offers a review of HEDIS essentials, gives you the tools you need to meet, document, and code HEDIS measures, and helps ensure quality care delivery for your patients.
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. For more details about renewals and fees, please visit https://nursing.ohio.gov/state-of-ohio-certified-doulas.
HEDIS records request
Each year from January through April, AmeriHealth Caritas Ohio conducts medical record reviews for a small group of members whose claims data show missing information or possible care gaps. During this time, you may receive requests from PalmQuest for medical records needed to complete this review. Your support helps ensure accurate quality reporting and better outcomes for 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.
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 (through 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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Topic
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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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March is National Kidney Month
National Kidney Month during March is a reminder to give our kidneys a check-up. Statistics show that 1 in 3 Americans are at high risk for kidney disease because of diabetes, high blood pressure, or a family history of kidney failure. On top of that, 30 million Americans already have kidney disease, and many of them are not aware of it because symptoms usually don't show until the disease has progressed.
Our kidneys are crucial for three main reasons. They regulate water, they remove waste and regulate minerals, and they produce hormones. Located in our lower back, these two hard-working organs also filter 200 liters of blood a day! Keeping our kidneys healthy is vital to a long and productive life.
Here are some steps to help protect your kidneys:
- Control your blood pressure (and diabetes if you have it). These are the two leading causes of kidney disease and kidney failure.
- Exercise often. Regular exercise keeps your kidneys healthy by keeping things moving and controlling blood pressure.
- Cut out processed foods. They tend to be big sources of sodium, nitrates, and phosphates, and they've been linked to kidney disease.
- Try to reduce over-the-counter pain medicines. They may help with aches and pains, but they can greatly damage your kidneys.
- Learn more about caring for your kidneys use #NationalKidneyMonth to share on social media.
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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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