Provider Partnerships - May 2026
A newsletter from AmeriHealth Caritas Ohio to better support those who care for our members.
Provider Site Visits – We Value Your Feedback
AmeriHealth Caritas Ohio Account Executives (AE) conduct routine site visits to ensure providers are well-connected with their assigned AE. Following the site visit, AmeriHealth Caritas Family of Companies corporate team will email a brief survey regarding your experience. 

We kindly ask that you take a few moments to complete and return the survey. Your feedback is valuable and helps us to continue to improve support and services. 

As always, we appreciate your partnership.

Access to Care

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

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

 

 

 

Self-collection for Cervical Cancer Screening

We want to support you in efforts to increase your patients’ cervical cancer screenings (CCS). We have identified an opportunity with BD Onclarity™ to offer the HPV Self-Collection Test Kits. It’s the first FDA-approved test for both HPV self-collection and extended genotyping.  

 

The HPV Self-Collection Test Kits are a less invasive alternative for your patients, our members, that is comparable in performance to cervical specimens, but no pelvic exam is required.

  • This screening option allows patients to collect their own sample without the need for a traditional endocervical specimen collection (Pap test) or pelvic exam.
  • BD Onclarity™ HPV self-collection looks like a long Q-tip and takes less than a minute to do in a private space at your office.
  • This can potentially increase screening participation rates, and more people being screened results in fewer cases of cervical cancer.

How to get started

For more information, to be connected with the BD Onclarity representative, please contact an AmeriHealth Caritas Ohio Account Executive.

 

HPV self-collection flyer (PDF)

 

Thank you for your ongoing partnership and commitment to quality care.

Collaborating to Enhance Population Health

Providing care for our shared members requires teamwork, communication, and a unified dedication to improving outcomes. Population health management aims to address care gaps, support those at highest risk, and promote comprehensive well-being across our communities. We strive to supply your practice with valuable tools and resources that complement the exceptional care you already offer.

 

Defined roles and shared accountability

Successful population health management relies on clear role definitions and aligned responsibilities. Together, we are accountable for achieving measurable health results.

 

Your practice:

  • Guides clinical decisions and oversees patient care.
  • Determines care needs during appointments and coordinates treatment plans.
  • Involves patients in recommended preventive and follow-up care as part of our health plan.

    Our health plan:

    • Supplies actionable data and quality performance reports.
    • Identifies members who could benefit from extra support.
    • Reaches out to engage members and reinforce care plans.
    • Offers care management services for members who are high-risk or have complex needs.
    • Connects members to community and social support services.

    By aligning responsibilities and maintaining open communication, we can coordinate outreach efforts and connect members to the appropriate care management and support programs, such as AmeriHealth Caritas Ohio’s Bright Start maternity care coordination program and/or Complex Care Management Program. We encourage providers to collaborate with us to refer eligible members and to reinforce engagement in available support services and programs.

     

    You lead your practice’s care; we provide support through data, coordination, and engagement. When we work together around shared goals and maintain clear communication, we can:

    • Address care gaps
    • Enhance quality performance
    • Minimize unnecessary utilization
    • Improve the member experience

    Advancing population health through value-based collaboration

    In addition to defining roles in coordinated care activities, we support providers through alternative payment model (APM) arrangements designed to align incentives with shared population health goals. These value-based strategies promote accountability for quality outcomes and care coordination, and facilitate overall member well-being by aligning performance expectations, data insights, and financial incentives. APM opportunities further strengthen collaboration and support measurable improvements in health outcomes throughout our communities.

     

    For more information about available resources, care coordination support, or value-based partnership opportunities, please contact AmeriHealth Caritas Ohio Provider Services 1-833-644-6001.

    New Policy for Sepsis Reimbursement

    AmeriHealth Caritas Ohio will be implementing a new Reimbursement Policy (Core Sepsis). Claims for select sepsis Diagnosis-Related Groups (DRGs)/All Patient Refined Diagnosis-Related Groups (APR-DRGs) may be subject to prepayment clinical validation using Sepsis-3 criteria to confirm that sepsis was present and that treatment services were appropriately rendered. Based on medical record review, hospital payment may be adjusted when documentation does not support sepsis and related treatment under Sepsis-3.

     

    Please note that inpatient services billed with a sepsis diagnosis with a length of stay of three days or less and a discharge status of home (01) or skilled nursing facility (03) may not be reimbursed. For compliance and reimbursement validation, Systemic Inflammatory Response Syndrome (SIRS), Severe Sepsis and Septic Shock: Early Management Bundle (SEP-1) criteria, or quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) scores alone are not acceptable as definitive evidence of a sepsis diagnosis. Please ensure the record includes clear, clinically supported documentation consistent with applicable regulatory and clinical guidelines.

    All-MCO Member Benefits Flyer
    A partner MCO is translating the benefits flyer into the following languages. It already exists in English and Spanish.
    • Arabic
    • Dari (Afghanistan)
    • French
    • Haitian French Creole
    • Kinyarwanda (Burundi)
    • Nepali/Nepalese
    • Pashtu (Afghanistan)
    • Russian 
    • Somali
    • Swahili
    • Ukrainian
    • Uzbek (Uzbekistan)
    • Vietnamese

    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

    Updated Billing Information on the Report of Pregnancy (ROP) and Perinatal Risk Assessment Form (PRAF)

     

    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.
    Best Practices to Ensure Accurate Payment and Directory Information 
    Questions About Reimbursement or Payment Policies?
    Click the appropriate link below for more detailed information.

    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:
    1. NaviNet (recommended method):
      • NaviNet > Forms and Dashboards > Provider Dispute Submission Form
      • The turnaround time is 15 days for disputes.
    2. Mail the form with your supporting documentation to: 
      • AmeriHealth Caritas Ohio
      • Attn: Provider Claim Inquiry
      • P.O. Box 7126
      • London, KY 40742
    3. Phone: 1-833-644-6001. Select the prompts for the correct department and then select the prompt for claim issues.
    4. 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
    1. Fax: 1-833-564-1329
    2. Mail the form with your supporting documentation to:
      • AmeriHealth Caritas Ohio
      • Attn: Provider Claim Inquiry
      • P.O. Box 7400
      • London, KY 40742
    NaviNet
    Let Us Know – Member Intervention Form Update

    Currently, providers can  Let Us Know if a member requires support by completing the Member Intervention Form, which is available on our plan website, and faxing it to our Rapid Response Outreach Team (RROT) 1-833-564-3290. The form can be used to assist members with  issues such as:

    1. Missed appointments
    2. Behavioral health needs
    3. Medication noncompliance
    4. Care management engagement
    5. Developmental screening concerns
    6. Emergency room misutilization
    7. Understanding plan benefits
    8. Social determinants of health
    9. Tobacco cessation referrals

    Providers have the option of submitting the Member Intervention Form via the NaviNet Provider Portal. This transition will streamline the submission and notification process to the RROT.

    Submitting the Member Intervention Form in NaviNet

    1. Log in to the NaviNet Provider Portal.
    2. Go to the  Forms and Dashboards section under Workflows for AmeriHealth Caritas Ohio.
    3. Select the Member Intervention Form link.
    4. Fill out all relevant fields on the form.
    5. Click “Submit.”
    6. After submission, a confirmation message will appear:  Member intervention form Submitted.

    Routing and Support

    Once submitted, the Member Intervention Form is routed directly to the RROT to address any identified concerns.

    • A Care Connector from the RROT will contact the provider within 48 to 72 to confirm receipt and to ensure understanding of the request.
    • Outreach will then be made to the member and upon successful contact all requested interventions will be completed.
    • Upon completion, the provider will be notified of the outcome, whether successful or unsuccessful.

    For questions or help with completing the form, contact the RROT at 1‑833‑464‑7768 (TTY 1-833-889-6446).
    Overpayment Recovery Enhancement
    1. 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.
    2. Forms and Dashboards > Overpayments
    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.
    NaviNet Claim Disputes Status Check Update
    AmeriHealth Caritas Ohio and NantHealth | NaviNet expanded the functionality for the submission of disputes regarding claim issues and supporting documentation to include the capability of viewing the status of the dispute and a copy of the determination letter. Click to read the entire notice. 
    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.
    Prior authorizations

    Q2 2026 CMS Quarterly Code Update

    Beginning April 1, the prior authorization status has changed for some HCPCS codes and services. Click to read the notice.
    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

    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 1-833-735-7700.

    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.

     

      
    Resources

    PCP Change Fform

    Do you have a patient whose Member ID card does not have you listed as their assigned PCP? You can use the PCP change form to request a change to a member's PCP. Access the form here. 

     

    Links

    Provider claims and billing manual

    Provider claims and billing webpage

    NaviNet provider portal

    Training and education

    EPSDT Billing

    Quick Reference Guide
    Training
    Only Two CEU Opportunities Left in the Project ECHO Series!
    AmeriHealth Caritas Ohio, in collaboration with Project ECHO, is offering a free case-based learning model for practitioners:  Engage, Empower, Treat: A Behavioral Health ECHO Learning Series.
     

    Date

    Topic

    June 11

    Attention Deficit Hyperactivity Disorder (ADHD) in Adults

    July 9

    Start the Conversation: Assessment and Intervention for Alcohol Use
     

    View the flyer for complete details. 

    For registration instructions, email: projectecho@amerihealthcaritas.com.
    Additional Free CEU Opportunities
    AmeriHealth Caritas Ohio is an accredited Continuing Education provider for Ohio Counselors, Social Workers, & MFT’s.
     
     Join us on June 17 for Suicide Prevention and Intervention. Click here to register.

    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. 

    Upcoming Conferences

    If you are attending any of the conferences below, we encourage you to stop by our booth to connect with our Account Executive team and pick up some AmeriHealth Caritas Ohio branded items.

     

    Date

    Organization

    Event

    Location

    Wednesday, May 20

    Ohio Hospital Association (OHA)

    111th OHA Annual Meeting & Education Summit

    Columbus

    Thursday, August 6

    Ohio Rural Health Association

    2026 Ohio Rural Health Conference

    OSU Wooster Campus

     
    Employee Spotlight
    Tell us a little bit about where you’re from and where you went to school. I was born and raised in Dayton, graduated from Paul Lawrence Dunbar High School, and went to Ohio Medical Business College for Medical Billing and Coding.
     
    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 a part of a team that put people first. I had the pleasure of knowing a few of the current employees and their observations of the operations here were very insightful. It led me to believe that the company values the opinions of the employees and is willing to engage in conversation about innovative ways to improve operations and expand our footprint in the Ohio market. I wanted to be a part of a team that is not only committed to impacting the community in a meaningful way but also values the people that are dedicated to helping carry out that vision.
     
    What drew you to this profession? I enjoy helping people and feel like I am a part of a team that is dedicated to that. By building relationships with our providers, we ensure our members are receiving the care they deserve. This can help them live full and healthy lives without having to be overly concerned about the financial aspect of receiving the care they need.
     
    What do you like to do in your free time? Free time, what’s that? I have five children - four boys and one girl. Most of my days are filled with transporting children from practices, competitions, track meets, football and boxing activities, and their after-school jobs. I’m currently preparing for my second son’s high school graduation and his college 
     
    My future grad, Jadyn
     

    preparations. Whenever I get some free time, I am catching up on rest. AND eating! I will sneak away and have a good meal. I like to visit local places that I discover on Instagram or Facebook. My favorite restaurant will always be Pappadeaux.

     

      

    The hubby and I enjoying House of Creole in Columbus. I heard about it on Facebook. The food was great and I definitely recommend it!

     

    If you could have dinner with anyone in the world, dead or alive, who would it be? Why? If I could have dinner with anyone in the world, dead or alive, I’d pick my mom who passed in 2020.

     

    What are 2 apps on your phone you CANNOT live without? My guilty pleasure is playing games on my phone. My kids made a big deal out of me STILL playing Candy Crush so I decided to switch it up. Right now, I’m playing Block Blast, Bubble Bus, and Match Factory most often. I’ll look for something new in a few weeks as suggested by my children, but I absolutely love puzzle games! My daughter recently added me as her friend on Roblox. She wanted me to try it, needless to say, I’m sticking to the puzzles! 

     

    Any interesting facts about yourself that you’d like to share? All of my vehicles have to have a name. The car I am driving now is named Ruby 😊

     

    Tamarra Satterfield

    Provider Network Account Executive I Phone: 1-614-874-1640 

    tsatterfield@amerihealthcaritasoh.com

     

     

    One of my daughter's MANY dance competitions
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