AmeriHealth Caritas Ohio's Provider Partnerships

AmeriHealth Caritas Ohio providers must meet access standard guidelines as outlined in this publication to help ensure that Plan members have timely access to care.

AmeriHealth Caritas Ohio endorses and promotes comprehensive and consistent access standards for members to assure member accessibility to healthcare services. The Plan establishes mechanisms for measuring compliance with existing standards and identifies opportunities for the implementation of interventions for improving accessibility to healthcare services for members.

Providers are required to offer hours of operation that are no less than the hours of operation offered to patients with commercial insurance or comparable to the hours of operation offered to Medicaid Fee for Service patients. Appointment scheduling and wait times for members should comply with the access standards. The standards apply to healthcare services and medical and behavioral health providers.

AmeriHealth Caritas Ohio monitors the following access standards on an annual basis per AmeriHealth Caritas Ohio guidelines. If a provider becomes unable to meet these standards, he/she must immediately advise his/her Provider Network Account Executive or the Provider Services department at 1-833-644-6001.

The details of these requirements can be found on pages 34, 35 and 36 of the provider manual.

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.

Guideline	Definition	Time Frame	Exceptions /Limitations
Rejected Claims	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.	Par/Non Par Outpatient: 365 days from the begin date of service Par/Non Par Inpatient: 365 days from the discharge date of service	COB: 180 days from the date of the EOB EXCEPTIONS: Claims denied by the primary for Timely Filing will stay denied TFO
Initial Claim	A first-time submission on a UB04 or CMS1500 for services rendered to a member	Par/Non Par Outpatient: 365 days from the begin date of service Par/Non Par Inpatient: 365 days from the discharge date of service	COB: 180 days from the date of the EOB EXCEPTIONS: Claims denied by the primary for Timely Filing will stay denied TFO
Resubmission of a Claim	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.	Par/Non Par Outpatient: 365 days from the begin date of service Par/Non Par Inpatient: 365 days from the discharge date of service	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
Corrected Claims	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)	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	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
Dispute	A provider’s disagreement with the way a claim has processed/denied.	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
Recovery Dispute	A provider’s disagreement with a claim recovery project (AmeriHealth Caritas Ohio has sent a letter).	30 days from the date of the notification	Any provisions, exclusions or limitations outlined within contractual language
Account Executive Escalations	A provider contacting their account executive to escalate mishandled disputes/claims.	60 days from the date of denial, payment, or determination letter

Claim reconsiderations with dates of service (DOS) beyond 730 days cannot be considered for review for any reason.

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.

Ohio Department of Medicaid (ODM) updates

To stay up to date on ODM news, subscribe to the ODM Press.

Medicaid agreement revalidations

To complete revalidation, visit PNM & Centralized Credentialing.

Updated claim submission and adjudication FAQs

Claims and Prior Authorization Submission Frequently Asked Questions (FAQ)

Ohio Department of Medicaid email links

Electronic Data Interchange (EDI)

Fiscal Intermediary (FI)

Next Generation Ohio Medicaid program

Ohio Medicaid Integrated Helpdesk

OhioRISE

Provider Network Management module and Centralized Credentialing

Single Pharmacy Benefit Manager

Claims and billing

Comprehensive Payment Systems Errors Report

The Claims Payment Systemic Errors (CPSE) report is updated and posted monthly with a list of resolved issues.

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):
- NaviNet > Forms and Dashboards > Provider Dispute Submission Form
- 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).

Fax: 1-833-564-1329
Mail the form with your supporting documentation to:
- AmeriHealth Caritas Ohio
- Attn: Provider Claim Inquiry
- P.O. Box 7400
- London, KY 40742

Best practices to ensure accurate payment and directory information

Use the PNM portal for all provider changes: https://managedcare.medicaid.ohio.gov/managed-care/centralized-credentialing.
ODM can take up to 14 business days to approve and send changes
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 IHD@Medicaid.ohio.gov.

Questions about reimbursement or payment policies?

Click the appropriate link below for more detailed information.

Clinical Policies

Clinical Practice Guidelines

Reimbursement Policies

NaviNet

New to NaviNet?

If you do not have access to the NaviNet provider portal, please visit: https://register.navinet.net/ to sign up. 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

If you have questions, please contact your Provider Account Executive or the Provider Services department at 1-833-644-6001.

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.

Overpayment recovery enhancement

NaviNet now offers the chance to review, approve or dispute claims overpayments and submit supporting documentation electronically in real-time. This functionality allows providers a more efficient way to respond to overpayment letters. It will help reduce the need to mail written correspondence and minimize response times.
Forms and Dashboards > Overpayments

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

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.

Prior authorizations

Helpful prior authorization information

The most up-to-date list of services requiring prior authorization is 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.

Go to: Prior Authorization Lookup Tool
Enter a CPT or HCPCS code.
Click Submit.
The tool will tell you if that service needs prior authorization.

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 1-833-735-7700.

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.

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 at 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.

Behavioral health

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 OhioRISE enrollment becomes effective the first day of the calendar month in which eligibility is established. This change is intended to align with OhioRISE managed care program enrollment and to reduce manual retro-enrollments related to an inpatient behavioral health admission. The rule change is expected to take effect July 1.

Clarification regarding financial responsibility for behavioral health services delivered to children and youth is outlined in the OhioRISE Mixed Services Protocol (the "Protocol"). Managed care plans will remain responsible for CANS assessments completed prior to OhioRISE enrollment. The Protocol will be updated as necessary to support the rule change.

This change, which makes OhioRISE retro eligibility effective on the first day of the calendar month in which a member becomes eligible, may result in previously paid behavioral health claims being recouped so the claim can be resubmitted to the OhioRISE plan for processing.

CEU opportunities
Sign up to receive notifications of FREE CEU trainings provided by AmeriHealth Caritas of Ohio.

Submitting prior authorization (PA) requests for behavioral health services

See the tip sheet for guidance on submitting PAs for behavioral health service requests.

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 here. 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. Click here for more details on this process.

Resources

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.

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.

Resources

Provider claims and billing manual

Provider claims and billing webpage

NaviNet provider portal

Training and education

EPSDT Billing Quick Reference Guide

Training

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.

View the flyer for complete details.

For registration instructions, email: projectecho@amerihealthcaritas.com.

Date	Topic
May 14	Managing Behavioral Health Conditions During the Perinatal Period
June 11	Attention Deficit Hyperactivity Disorder (ADHD) in Adults
July 9	Start the Conversation: Assessment and Intervention for Alcohol Use

Additional free CEU opportunities

Date	Topic
April 28	Preventing Adverse Childhood Experiences and Mitigating their Negative Impacts on Ohio Children and Families
June 17	Suicide Prevention and Intervention

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.

Cultural competency

AmeriHealth Caritas Ohio is committed to promoting education and awareness of culturally and linguistically appropriate services (CLAS) and to combating the effects of low health literacy on the health status of our members.

Employee spotlight

Tell us a little bit about where you’re from and where you went to school. I was born, raised and still reside in Youngstown. I attended Youngstown State University, where I earned my Bachelor of Science in Public Health (BSPH).

Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours? I found myself displaced after being with another large MCO for almost twenty years. I was looking for something similar and terrified I wouldn’t find a position locally in my field. I came across a friend sharing AmeriHealth Caritas Ohio’s job posting for a position that was exactly what I had been doing. I did some research about the company and was so blown away at all the great work being done for the community and applied. The rest is history. I jumped in without skipping a beat, I feel like I have been here for years. My teammates, and all the staff, welcomed me with open arms and I am happy to work for a company that genuinely cares about the wellbeing of their members and offers support to help them achieve their best health.

What drew you to this profession? Years ago, after working in numerous careers, I started working for a health insurance company and it sparked my interest in this field. After a healthcare scare in 2012, I decided to continue my education in this line of work because I wanted to be a part of advocating for others to be active in their own healthcare and take preventative measures to assure they live to their healthiest potential.

My Grandson Junie. He lights up my life!

What do you like to do in your free time? I roller skate once a week. I’m known as "the lady with leopard skates!" I love to attend music concerts of all genres and comedy shows. But, most importantly, I love spending time with my grandson. I am a mom of two girls and finally I get to experience boy stuff!

I started skating again in 2021 and have made so many forever friendships. My skates are a great conversation starter!

If you could have dinner with anyone in the world, dead or alive, who would it be? Why? I would choose Dolly Parton. I have loved her since I was a little girl - her music, her story of rising from poverty to stardom, and most notably her philanthropy aimed at helping others.

What are 2 apps on your phone you CANNOT live without? The SNKRS app, for I have quite an obsession with sneakers. It keeps me up to date on any new releases and pairs that come out that I want but don’t NEED! The other app is Pinterest. I love looking up recipes to try and ideas for home improvement and decoration.

Any interesting facts about yourself that you’d like to share? A fact about me that some would find surprising is I once worked for a traveling plumbing company right out of high school. I was responsible for converting households with well water to the city water mains which included climbing under trailer homes in all weather conditions, and soldering pipes.

Angela Andujar

Provider Network Account Executive II Phone: 1-330-360-9607

aandujar@amerihealthcaritasoh.com

Building trust to strengthen well-child visits

The importance of well-child visits in pediatric care

Well-child visits serve as a fundamental component of pediatric care, providing health care providers with essential opportunities to monitor children’s growth and development, deliver preventive services, and foster trusted relationships with families.

These visits are particularly significant for addressing disparities in preventive care. For example, a 2020 study within a large health care system found that 71% of white children were up to date with their well-child visits, compared to only 64% of Hispanic/Latino children and 59% of Black children.¹ For Black/African American children, well-child visits also present critical moments to address disparities in timely immunizations and other preventive screenings. By prioritizing culturally responsive communication and patient-centered care, providers can help improve adherence to recommended visits, reduce health inequities, and support healthier futures.²

Challenges and barriers to preventive care

Preventive care in childhood is essential for encouraging healthy growth, facilitating early screenings, and ensuring children receive timely immunizations consistent with national recommendations.³ Yet, racial and ethnic disparities in preventive care persist. Black/African American children are less likely to be fully immunized by age two, compared with their white and Latino peers.^4,5 This gap may be caused by mistrust of the healthcare system, transportation issues, and scheduling problems, which can lead not only to vaccine delays but also to missed well-child visits.⁶ Each visit becomes more than just a routine checkup. It is an opportunity for providers to build trust, address family concerns, and equip parents with the information needed to support their child’s health.⁷

Five strategies for building trust and strengthening well-child visits

Review care gaps by race and ethnicity. Examine your practice data by race and ethnicity to identify missed visits, incomplete vaccinations, or other disparities. Pay particular attention to vaccines, such as DTaP and flu, as these often reflect broader gaps in preventive care.⁵
Acknowledge mistrust. Recognize that families may have concerns rooted in historical and ongoing inequalities. Responding with empathy and clear explanations can help build trust.⁸
Connect preventive care to family priorities. Go beyond simply saying vaccines are “safe and effective.” Frame the benefits in ways that resonate with parents. For example, “This helps keep your child healthy, in school, and protected from serious illnesses.”⁷
Address practical barriers. Engage families in conversations about challenges they encounter with transportation, time off work, or scheduling. Providing solutions such as flexible hours, reminders, and connections to ride assistance programs can make a significant impact.⁶
Create space for open dialogue. Encourage questions and listen closely to family concerns about vaccines, nutrition, or development. Dialogue, instead of one-way information, helps build confidence and makes guidance more meaningful.⁷

Well-child visits provide essential opportunities to build trust, overcome barriers, and fill care gaps. By communicating clearly and remaining attentive to the unique challenges faced by Black/African American families, providers can help ensure every child has the chance to grow up healthy and supported.

References

Amanda Luff, et al., “Attendance patterns in well-child visits across diverse pediatric populations, Midwestern United States,” Preventive Medicine Reports, Vol. 54, Article 103082, June 2025, https://doi.org/10.1016/j.pmedr.2025.103082, accessed February 13, 2026.
Joseph F. Hagan, Jr., et al. (Eds.), Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (4th ed.), American Academy of Pediatrics, 2017.
Centers for Disease Control and Prevention. (2026). Child and Adolescent Immunization Schedules. https://www.cdc.gov/vaccines/imz-schedules/child-easyread.html, accessed February 16, 2026.
Cierra Buckman, et al., “The influence of local political trends on childhood vaccine completion in North Carolina,” Social Science & Medicine, Vol. 260, Article 113187, September 2020, https://doi.org/10.1016/j.socscimed.2020.113187, accessed February 13, 2026.
Trisha C. Parker, et al., “Rotavirus vaccination rate disparities seen among infants with acute gastroenteritis in Georgia,” Ethnicity & Health, Vol. 22 , No. 6, pp. 585–595, October 14, 2016, https://www.tandfonline.com/doi/full/10.1080/13557858.2016.1244744, accessed February 13, 2026.
Lavanya Vasudevan, et al., “Vaccine hesitancy in North Carolina: The elephant in the room?” North Carolina Medical Journal, Vol. 82 , No. 2, pp. 130–137, March 1, 2021, https://doi.org/10.18043/ncm.82.2.130.
Monica Schoch-Spana, et al., “The public’s role in COVID-19 vaccination: Human-centered recommendations to enhance vaccine acceptance, uptake, and equity,” Vaccine, Vol. 39 ; No. 40, pp. 6004–6012, September 24, 2021, https://doi.org/10.1016/j.vaccine.2021.09.012, accessed February 13, 2026.
Giselle Corbie-Smith, “Vaccine hesitancy is a scapegoat for structural racism,” JAMA Health Forum, Vol. 2 ; No. 3, Article e210434, March 25, 2021, https://doi.org/10.1001/jamahealthforum.2021.0434, accessed February 13, 2026.

Observed every year in April, National Minority Health Month focuses on strengthening efforts to reduce health disparities among racial and ethnic minority populations. It promotes awareness of the disproportionate burden of disease and premature death in these communities while encouraging equitable access to quality healthcare, particularly primary and family care.

The origin of National Minority Health Month was the 1915 establishment of National Negro Health Week by Booker T. Washington.

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