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.
NEW! Tobacco Cessation Member Support and Coding Best Practices
Take a look at AmeriHealth Caritas Ohio's new tobacco cessation CPT guide, an effective tool that combines recommendations on providing members support and best practices for coding counseling sessions.
New Policy - Core Sepsis
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.
Ohio Launches New Medicaid Fraud Prevention Measures: What EVV Providers Need to Know Governor Mike DeWine has announced a series of new initiatives aimed at strengthening the state’s efforts to prevent fraud, waste, and abuse within the Medicaid system. His initiatives to combat fraud, waste, and abuse include a 6-month moratorium on new Medicaid enrollments for Hospice, Home Health, Waiver individuals and organizations, Private Duty nurses, personal care aides, and home care attendants.
While these reforms impact a broad range of home- and community-based service providers, they carry especially significant implications for Electronic Visit Verification (EVV) providers and organizations relying on EVV for claims payment. Proposed changes include the following:
Mandatory GPS for All EVV Systems
EVV Requirement Extended to Live-In Caregivers
Per Diem Services Subject to EVV
Increased Scrutiny Through Analytics and Red-Flag Monitoring
More Frequent Revalidation for High-Risk Providers
Statewide Moratorium on Home-Health and Hospice Providers
New Materials and On-Demand Coding Primer on the CPT 2027 Restructure for Maternity Care Services Codes
The American Medical Association (AMA) hosted the Current Procedural Terminology (CPT®) Webinar, “A Coding Primer: Previewing the CPT 2027 Restructure for Maternity Care Services Codes,” which is now available for replay for guidance on coding and more from AMA and American Hospital Association coding experts.
This month, we’re helping providers simplify hospital billing with practical tips to avoid common pitfalls, ensure prompt payment, and master the basics of interim billing.
For hospitals reimbursed via DRG- prospective payment system
Hospitals that are subject to the prospective payment system (DRG) should utilize bill type 112 as defined by the National Uniform Billing Committee (NUBC).
Ensure correct alignment with admission dates for your bill type When reporting the admission date, it’s imperative that the admission date for any 113 bill types should align with the admission date of the preceding 112 bill type. Aligning ensures accuracy and consistency in the billing process.
Unlike 112 bill types, 113 bill types do not require an admission date to fall within the “statement covers period” date span. This flexibility allows more leeway with the submission of bills under specific circumstances.
Ensure interim bills meet the minimum covered days requirement Interim bills submitted should account for a minimum of 30 covered days.
Include a patient status code Including the patient status code is essential for proper billing procedures. Providers must use patient status code 30 to indicate that the patient is still within the healthcare system.
Void interim billing at discharge At the time of discharge, providers must void ALL interim bills via EDI transactions or through the provider portal utilizing frequency code 8. All interim bills must be voided before submitting the final admit-through-discharge bill (type 111) to ensure accurate payment of the final claim
Submit a final admit through discharge bill In this case completeness matters. The final claim (type 111) must encompass a complete billing cycle from admittance to discharge. This bill must reiterate and encompass all charges submitted on prior advanced interim bills to provide a comprehensive, accurate portrayal of the patient's care.
For hospitals exempt from DRG- based reimbursement
Hospitals exempt from DRG- based reimbursement system must use bill type 112 (NUBC-defined) for interim bill payments.
Ensure correct alignment with admission dates for your bill type When reporting the admission date, it’s imperative that the admission date for any 113 bill types should align with the admission date of the preceding 112 bill type. Aligning ensures accuracy and consistency in the billing process.
Unlike 112 bill types, 113 bill types do not require an admission date to fall within the “statement covers period” date span. This flexibility allows more leeway with the submission of bills under specific circumstances.
Ensure interim bills meet the minimum covered days requirement Interim bills submitted must account for a minimum of 30 covered days.
Include a patient status code Including the patient status code is essential for proper billing procedures. Providers must use patient status code 30 to indicate that the patient is still within the healthcare system.
Submit a final admit through discharge bill At the time of patient discharge, providers must submit the final claim utilizing bill type 114. This claim should only include the remaining days and charges since the last submitted interim bill. This bill can be less than 30 days.
By following these steps, providers can remain billing compliant and avoid any potential delays in payment.
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)
Best Practices to Ensure Accurate Payment and Directory Information
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 ODM's Integrated Helpdesk at IHD@Medicaid.ohio.gov or 1-800-686-1516.
Questions About Reimbursement or Payment Policies?
Click the appropriate link below for more detailed information.
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:
Mail the form with your supporting documentation to:
AmeriHealth Caritas Ohio
Attn: Provider Claim Inquiry
P.O. Box 7400
London, KY 40742
NaviNet
NaviNet®DisputeLetter Access Update
The location of disputeletters in the NaviNet Provider portal has changed. Effective July 30, 2026, providers can access disputeletters in NaviNet by:
Navigating to Plan Central > Workflows > Patient Documents
Using the updated location to view all dispute letters by member name.
Discontinued: dispute letters will no longer be available under Practice Documents.
This update improves efficiency and reduces time spent searching for member-specific letters by:
Displaying each letter clearly by member name.
Eliminating the need to open multiple files to identify the correct member.
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
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
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 p.m. ET, Monday through Friday, except for holidays. The UM department can be reached at:
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
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.
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:
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.
Behavioral Health
Behavioral Health Service Thresholds Effective 10/1 The Ohio Department of Medicaid recently approved utilization management policies for certain community behavioral health services, effective July 1. AmeriHealth Caritas Ohio will not be implementing the changes until October 1.
Any services rendered before July 1, will not count toward the authorization thresholds.
Services rendered between July 1 and September 30, will count toward the thresholds.
The Child and Adolescent Needs and Strengths (CANS) assessment plays a vital role in determining eligibility for OhioRISE enrollment. For CANS certified assessors who complete these assessments and submit claims for reimbursement, it is essential to enter
completed assessments into the ODM CANS IT Portal within 10 business days. Timely submission not only streamlines the enrollment process but also ensures that children and youth receive critical behavioral health services without unnecessary delays.
Delays in submitting assessments through the portal can significantly impact access to care, potentially postponing the support children, youth and families need for their behavioral health. To promote consistency and provide high-quality care, AmeriHealth requests all CANS certified providers to adopt a standardized process and consistently submit assessments within the 10-day timeframe. By doing so, providers help safeguard timely access to vital services and improve outcomes for those in need. Additionally, delays in submitting CANS assessments in the portal within the 10-day timeframe from the date of service listed on the claim could impact payment of services.
Changes to eligibility for OhioRISE members
The Ohio Department of Medicaid has amended the OhioRISE eligibility and enrollment rule, 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.
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. Read rule 5160-59-02 | OhioRISE: eligibility and enrollment here.
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
Helping Members Get to Care: AmeriHealth Caritas Ohio Transportation Benefits
Transportation barriers can prevent members from accessing important preventive, primary, specialty, behavioral health, and other covered healthcare services. AmeriHealth Caritas Ohio offers transportation assistance to help eligible members get to and from covered healthcare appointments and services.
Providers play an important role in helping members overcome barriers to care. When transportation challenges are identified, providers can help connect members with available transportation resources before missed appointments become an issue.
Transportation Assistance Available
AmeriHealth Caritas Ohio members may qualify for non-emergency medical transportation (NEMT) to covered healthcare services, including:
Primary care appointments
Specialist visits
Behavioral health services
Dialysis treatments
Hospital discharges
Pharmacy visits (when applicable)
Other medically necessary covered services
Transportation may be provided through a variety of options based on the member's needs, including rideshare services, mileage reimbursement, public transit assistance, wheelchair-accessible transportation, or other transportation arrangements.
How Members Can Request Transportation
To schedule a ride members can contact our transportation vendor, MTM directly at 1-833-664-6368. Or call AmeriHealth Caritas Ohio Member Services at 1-833-764-7700 (TTY 1-833-889-6446), 24 hours a day, seven days a week.
Providers may also remind members to:
Schedule transportation 48 hours to 30 days in advance whenever possible
Have their appointment date, time, provider name, and address available when calling
Notify MTM if an appointment is cancelled or rescheduled
Need Help?
Members with questions about transportation benefits or eligibility can contact AmeriHealth Caritas Ohio Member Services at 1-833-764-7700 (TTY 1-833-889-6446). Our team can help connect members to the appropriate transportation resources and answer questions about available transportation benefits.
Looking for more details? You can find more information about our transportation benefits here: Transportation.
PCP Change Form
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.
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
Thursday, August 6
Ohio Rural Health Association
2026 Ohio Rural Health Conference
OSU Wooster Campus
Virtual Provider Orientation
AmeriHealth Caritas Ohio invites you and your staff to join us for a virtual New Provider Orientation session. Click here to register.
September 15
November 17
Employee Spotlight
Tell us a little bit about where you’re from and where you went to school.I am originally from the sunshine state of Florida, I relocated to Lewis Center, Ohio, in elementary school. I later attended Columbus State Community College, where I earned a degree in Health Information Management and Technology. My educational background provided a strong foundation in healthcare information systems, data management, and technology, supporting my commitment to improving member and provider care.
Everyone at AmeriHealth Caritas Ohio has a story about why they joined the team. What’s yours?I was drawn to join AmeriHealth Ohio by the opportunity to be part of a new Managed Care for the Next-Gen ODM initiative of healthcare. The chance to select and hire an entire team with partners and build it from the ground up was exciting, and a truly rare opportunity. Being able to shape my team’s culture, establish a strong foundation, and contribute to something new and meaningful made this opportunity one I didn’t want to pass up. To date, I am exceptionally proud of what my team and I have accomplished. We have built innovative solutions such as provider data automation, enhanced claims processing capabilities for our line of business, in addition to delivering many other improvements that have strengthened our operations.
What drew you to this profession?I have always been passionate about healthcare, however what drew me to operations is that I enjoy working as "the wizard behind the curtain" to make a meaningful impact in healthcare. I take pride in helping reduce administrative barriers so providers can focus on delivering high-quality care to our members. I am passionate about solving complex challenges and driving process improvements that enhance efficiency, streamline operations, and improve healthcare accessibility for everyone involved.
What do you like to do in your free time? When I'm not at dance practice with my children, you'll likely find me at dance competition cheering them on. In the rare moments of downtime, I enjoy crocheting, tackling DIY home improvement projects, getting lost in a good book outside in the hammock with a glass of wine, and most importantly, spending quality time with my family and loved ones.
If you could have dinner with anyone in the world, dead or alive, who would it be? Why?If could have dinner with anyone, it would be my dad who passed away in 2024. I would love the opportunity to share one more meal with him while watching fireworks he never had the chance to see that year, while having one last conversation to soak up his laugh and hugs. He is deeply missed every day, and I would cherish the chance to tell him how much he will always mean to me and my children.
What are 2 apps on your phone you CANNOT live without?The two I can't live without are my calendar and either Audible or Kindle. My calendar keeps my family's busy schedule organized, while Audible and Kindle make it easy to enjoy a good book whenever I have a few spare moments.
Any interesting facts about yourself that you’d like to share? Something unique about me? I have a hard time leaving well enough alone- in the best way possible. If it can be customized, built, baked, sewn or created from scratch, I'm probably already working on it. I love designing custom items for family & friends, building personalized closets, making cozy blankets, cutting kids' hair, and cooking just about everything from scratch.
