Welcome to the September newsletter!
September 2023

Upcoming: daily provider data reconciliation to the Provider Network Management (PNM) and Provider Master File (PMF) system

Effective October 21, 2023, the Ohio Department of Medicaid has mandated the following to all Managed Care Organizations.


With the PNM system generated PMF as the Ohio Department of Medicaid’s (ODM) system of record, MCEs must direct ALL providers to update their ODM record in the PNM system when discrepancies are identified between the MCE’s data and the PNM PMF. Ohio Administrative Code rule 5160-1-17.2(F) requires all providers with a signed Medicaid provider agreement to “inform ODM within thirty days of any changes including, but not limited to changes in licensure, certification, or registration status; ownership; specialty; additions, deletions, or re-placements in group membership and hospital-based physician affiliations; and address, including all locations where servicers are rendered.” MCEs must not accept changes from providers into their own systems that are inconsistent with PNM system data shared through the PNM PMF for their Medicaid line of business.


To ensure the prompt and timely payment of claims for services rendered to Medicaid managed care members, the MCE must integrate and use PNM system data (PMF and all supplemental files generated by ODM systems) for claims adjudication and payment.


We will share more information as we receive it from the Ohio Department of Medicaid.

Do not send paper claims 

The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). If you have submitted a paper claim, you will be advised that your claim has not been processed and what your next steps should be. You can get started on our website with claims how-tos, quick guides, links and contact info.

Changes to OhioMHAS Licensure and Certification Requirement 
In July, Governor Mike DeWine signed the Ohio Fiscal Year SFY 2024 - 2025 operating budget bill into law. House Bill 33 includes new statutory requirements for new and currently licensed and/or certified community behavioral health services providers, private psychiatric hospitals, and residential Class 1, 2, and 3 facilities. Click here to read a summary of the new statutory requirements.
Prior authorizations
Did you know you can submit prior authorizations through the NaviNet portal?
AmeriHealth Caritas Ohio created this tool to provide a higher auto-approval rate and quicker turnaround time compared to faxing the authorizations. There is also a report function that gives a status report allowing you to have visibility to all prior authorization requests you have submitted.
We are happy to offer training or any assistance your team may need to transition to this process. Please reach out to your local Account Executive.
Click here to log into NaviNet.

NaviNet dispute process 

Provider claim disputes are any provider inquiry or request for reconsideration. They range from general questions about a claim to a provider disagreeing with a claim denial. 


Disputes can be filed directly with NaviNet using any of the following methods:

  • Phone: 1-833-644-6001 (select the prompts for the correct department and then select the prompt for claim issues)
  • Online NaviNet
  • Mail:
    AmeriHealth Caritas Ohio
    Attn: Provider Claim Inquiry
    P.O. Box 7104
    London, KY 40742
  • Fax: 1-833-216-2272
Click here to watch a tutorial video with step-by-step instructions on how to file a claim.Access the Provider Dispute Submission FormSign up for NaviNet
Tools in NaviNet - Medicaid Member Annual Eligibility Redetermination
In an effort to help ensure that AmeriHealth Caritas Ohio members continue to receive Medicaid benefits from the Ohio Department of Medicaid, AmeriHealth Caritas Ohio has launched two new tools in the NaviNet provider portal that will allow providers to view upcoming Medicaid Member Annual Eligibility Redetermination (Recertification) dates. 
The following tools are available in the NaviNet Provider Portal:
  • Medicaid Member Annual Eligibility Redetermination Popup Alert
    In the Eligibility and Benefits Screen under the Patient Alert Details popup, there will be a new “Redetermination Report” link that, when clicked, will display the member’s upcoming eligibility redetermination date.  The new pop-up alert will be very similar to the existing Care Gap and PCP History alerts and will be available to all provider types.

  • Medicaid Member Annual Eligibility Redetermination Report
    In the Administrative Report Inquiry section, a new report will be available for PCPs under the report list dropdown that provides a full list of all members on your roster who have upcoming eligibility redetermination dates.  The report will be available for PCPs to download in both PDF and excel formats.
Call to action
You can use these new tools to verify AmeriHealth Caritas Ohio members (your patients) Medicaid Annual Eligibility Redetermination status. If you receive an alert or report in NaviNet that indicates your plan member has an upcoming eligibility redetermination date, you can help ensure their continued coverage by stressing the urgency of timely recertification and directing those in need of assistance to us at 1-833-764-7700 (TTY 1-833-889-6446). 
Timely recertification is important because it:
  • Helps ensure continuity of care for our plan members/your patients.
  • Eases administrative burden when verifying member eligibility.
  • Avoids the need for resubmission of prior authorization requests for certain services that may be required due to gaps in care caused by lapsed Medicaid coverage.
  • Supports timely deeming of newborns as Medicaid eligible and ensures mom and baby are both on the AmeriHealth Caritas Ohio plan.
If you have any questions, please feel free to contact your AmeriHealth Caritas Ohio Provider Account Executive or Provider Services at 1-833-644-6001. AmeriHealth Caritas Ohio members who require assistance should be directed to us at 1-833-764-7700 (TTY 1-833-889-6446). 
Value-added benefit: Living Beyond Pain 
 September is National Pain Awareness month. One of the additional benefits we offer our members is the Living Beyond Pain program. The Living Beyond Pain program offers qualifying members the ability to receive acupuncture or chiropractic visits as an 
alternative to opioid prescriptions. This includes 15 additional chiropractic and 30 acupuncture visits per year for members who do not qualify for the state benefit. Referrals to the program can be made to the care coordination hotline at 1-833-464-7768.






New form required when requesting an Administrator change across organizations
Ohio Department of Medicaid (ODM) developed a new form, ODM10304, that must accompany requests to change Provider Network Management (PNM) Administrators from one billing organization provider to another. As a security measure, you must submit a formal request to transfer Administrator ownership of a Medicaid ID within the PNM module. More details are available on ODMs website


Claim submission and adjudication FAQ is now available

ODM updated the Claims and Prior Authorization Submission Frequently Asked Questions (FAQ) to make it easier for you to find the information you need. It covers fee-for-service, managed care, and OhioRISE billing procedures, adjudication processes, and other answers to common provider questions. Review this document on the submitting claims and prior authorizations page on the Next Generation website and share it within your practice or organization. 
If you have questions, providers can contact the ODM Integrated Helpdesk (IHD) at 800-686-1516 or IHD@medicaid.ohio.gov. Representatives are available 8 a.m.-4:30 p.m. Eastern time Monday - Friday.


Updated HEDIS Guidelines for the Care Gap Closure program  

Click here to view the HEDIS 2023 Documentation and Coding Guidelines.


Ohio Department of Medicaid fraud warning

Criminals are targeting Medicaid recipients for sensitive, personal, and financial information. If your patient gets a call, text, or email about Medicaid benefits asking for a Social Security number, payment, bank, debit, or credit card information, advise your patient to not respond. They’re not from the State of Ohio or any agency. Instead, it should be reported to the Ohio Attorney General at 800-282-0515 or click here

Resources and reminders

Provider Claims and Billing Manual - Box 33, no PO Box allowed 

33 Billing Provider Info & Ph. # Required – Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location; P.O. Boxes are not acceptable R 2010AA NM103 NM104 NM105 NM107 N301 N401 N402 N403 PER04

See page 17 of Provider Claims and Billing Manual.


Important requirements for Hospice Billing of (HCPC T2046) and Ventilator/Ventilator Weaning Services

  • Hospice Nursing Facility R&B should be billed on a HCFA form. Be sure to include the name of the facility where services were rendered in box 32a.
  • Vent and Vent weaning claims should be billed on a UB form with Type of bill 81X/081X. If this bill type is not used the claim will deny.
  • On Vent and Vent weaning claims, the diagnosis of Z99.11 should be present.
  • Vent and Vent weaning claims require the provider to include the name and NPI of the NF where services were rendered in box 80 (Remark code).

If the above conditions are not met, the claim may be denied and require submission of a corrected claim. 

Do not send paper claims

The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). If you have submitted a paper claim, you will be advised that your claim has not been processed and what your next steps should be. You can get started on our website with claims how-tos, quick guides, links and contact info.


Medicaid Annual Eligibility Redetermination Reviews

Information for providers regarding Annual Eligibility Redetermination Reviews is on our website. This federally required process is in place to ensure those enrolled in Medicaid programs continue to meet established eligibility criteria. AmeriHealth Caritas Ohio will collaborate with Ohio Department of Medicaid and our provider network to minimize the burden on our members and promote continuity of health coverage.


Billing guidelines

Clarifying language is being added to the behavioral health section of our billing guidelines: For services billed under the provider’s primary license, optional modifiers are not to be used.


Access AmeriHealth Caritas Ohio's provider resources

Step 1: Visit our provider webpage
Step 2: Sign up for NaviNet
Step 3: Attend a Provider Orientation Meeting
Step 4: Submit claims through Electronic Data Interchange (EDI)

Trauma-Informed Care resources
Trauma can have serious effects on people’s health, behaviors, relationships, and other aspects of day-to-day life. Healthcare providers of all disciplines are encouraged to learn more about trauma-informed care (TIC) with the resources on our website
Virtual office hours
Got Questions? Let us help you. Join the ACOH Provider Services team for a virtual office hours. Our team will be here to help answer your questions or help you navigate our provider resources. We will be offering virtual office hours with no registration necessary. 
October 19, Noon - 1:00 p.m. click to join
November 16, Noon -1:00 p.m. click to join

Value-based programs

  • CMC/CPC Resource Guides: provide MCO Universal Documents, Consolidated information for all plans such as benefits and key contact information, and education material related directly to the ODM initiative.
  • PerformPlus® Gaps in Care Closure Program for 2023: Program rewards Ohio CPC primary care practices for each member attributed to the practice who receives the recommended wellness or preventive care measures (9 Total Measures).  Ohio CPC providers will be paid $30 per gap closure for their attributed members.
  • PerformPlus Portfolio: PerformPlus is a suite of value-based incentive programs designed to improve quality, efficiency, patient satisfaction, and provider experience. Programs are available for primary care providers, small and rural-based providers, physical and behavioral health specialists, dental providers, federally qualified health centers (FQHCs), hospitals, integrated delivery systems, nursing facilities, home health providers, long-term services and supports (LTSS), and community-based organizations (CBOs)

Visit our website to view the resources. 

Claims Payment Systemic Error (CPSE) report

The Claims Payment Systemic Errors (CPSE) report is updated and posted on the ‘Alerts and Newsletter’ page monthly. AmeriHealth Caritas Ohio encourages you to review this log frequently and before contacting our Provider Services team. If after reviewing you still have additional questions, please feel free to reach out to Provider Services at 1-833-644-6001 and, as always, you can reach out to your local account executive.

Tell us a little bit about where you’re from. I was born in Westerville and grew up in Gahanna. I graduated from Gahanna Lincoln High School and Otterbein University for college. I earned a BA degree in Sports Management and have minors in Biology, Business and Religion.


Everyone at AmeriHealth Caritas Ohio (ACOH) has a story about why they joined the team. What’s yours? I worked for another MCO for seven years. A lot of major changes to processes and changes in leadership is what started my desire for a new challenge and fresh start. I was feeling very burnt out, overwhelmed and unfairly treated. One of my best friends was in a similar situation, working at another MCO, and recommended MCOs I should look into for new opportunities. I found ACOH in my search and it lined up with the values and culture I was looking for in a new opportunity. I was also intrigued to work with a company who was building and establishing itself in the state of Ohio.  


My family


What drew you to this profession?

A friend of mine got into this industry years ago and thought I would do well and enjoy this type of work. We are like-minded and have the same values of work/life balance. I enjoy problem-solving and helping others. So having an opportunity with this job was a great fit for me. I was drawn to the fact that ACOH is building something in Ohio and wanted to help champion this organization. And I wanted to add value to building provider relationships.

What do you like to do in your free time? I enjoy spending time with family and friends and being there for them. I love sports and follow the NBA, NFL and college football. I enjoy music, working out, playing basketball and attending my nieces and nephews sporting events. I am also a sneakerhead and enjoy sneaker culture. Always selling, adding and keeping up with my shoes. 


If you could have dinner with anyone in the world, dead or alive, who would it be? Why? It would definitely be my grandma. She passed in 2017 and I think of her every day since. She is a major influence in the man I am today and how I see things. She accomplished and did amazing things in her life that I greatly admire. She was a funny, supportive, caring, extremely loving and whip smart. I love her very much and carry her with me always. She was a fantastic cook so having dinner with her would be better than anything, full of smiles and love. She was the greatest!


What are two apps on your phone you CANNOT live without? I would say Yahoo Sports and YouTube. I would say TikTok too, but it always leads me down a rabbit hole. I think I'm going in for a few minutes, then next thing I know two hours have passed! So I could live without TikTok but enjoy it just the same.


Any interesting facts about yourself that you’d like to share? I won three track and field championships in college, 3 years in a row.  We have 4 Roberts in my immediate family and we each have roman numerals following our last names, I-IV. I am the II. I eat through the peel of oranges like people eat apples. I get an occasional weird look of shock if someone sees me eating oranges like that lol.

My contact info and territory: Rob Thompson
Counties: Coshocton, Delaware, Knox, Licking, Muskingum and Perry 
Click here to find your Account Executive
Join us for our next Coffee and Conversations with AmeriHealth

Stop by Panera on the morning of September 26 where you will be able to get to know your Columbus-area Account Executives and ask any questions you may have. The coffee is on us!


Time: Tuesday, September 26, 7:00 a.m. - 10:00 a.m.

Location: Panera, 300 W. Lane Avenue, Columbus

We would love to hear from you!

Your voice matters and we want to hear your thoughts regarding participation in AmeriHealth Caritas Ohio's Population Health and Quality initiatives. Click here to take the one-minute survey. 

September is Suicide Prevention and Awareness Month

The medical industry is a highly stressful field, particularly with the increased strain of the past few years. We provide tools to help our providers just as we offer tools to help our members. One of these is the Ohio State Medical Association's Well-Being CARE program. The Checkup And Referral Engagement service is a program to help monitor and improve the mental health of licensed medical professionals, medical students, and licensed training program participants. Healthcare workers complete an assessment for the current state of their mental health and wellbeing, which is reviewed by licensed mental health professionals who can provide personalized responses and recommendations. The program is anonymous, voluntary, and free. Providers can find more information at www.WellBeingCare.org.

Upcoming webinars 

New provider orientation sessions are available through 2023

We encourage providers to attend one of our new provider orientations. This ODM-required presentation offers us the opportunity to introduce ourselves to new providers. These presentations include information on our unique member benefits, value-based care program, claims and billing information and our provider portal NaviNet. Join your personal account executives online via Zoom from 10 a.m. - 11 a.m. on any of the dates below.


October 17 - click here to register

November 14 - click here to register.

December 19 - click here to register


We encourage you to register to attend one of these online webinars or to contact your local Account Executive to schedule an individual orientation 


If you attended an orientation session and need to complete the attestation, click here to get started.


Improving Outcomes for People with Disabilities 2023 virtual roundtable
Ohio Association of Health Plans and Ohio Center for Autism and Low Incidence (OCALI) are hosting a series of virtual roundtables. This series provides attendees the opportunity to hear from and engage with national experts and local leaders and deepen their understanding of people with disabilities as a focus of population health. The one-hour roundtables include lived experience, didactic presentation, and opportunity for interaction. Each session is designed to both challenge your thinking and change your practice, providing you with tools and resources you can use immediately. 
  • October 24 - Economic Stability: Employment 
  • November 28 - Social & Community Context: Family Caregivers
Click here to register. 
Continuous Glucose Monitors Learning Series

Continuous Glucose Monitors (CMGs) are associated with improved Hemoglobin A1c levels in adults with Type 2 diabetes covered by Medicaid. To improve outcomes for patients with diabetes, the Medicaid Managed Care Plans have removed Prior Authorization requirements for CGMs ordered through pharmacy or Durable Medical Equipment channels. AmeriHealth Caritas and other Medicaid Managed Care Plans are working with providers to integrate CGMs into their practice and are available to work with you. If you are curious about how to use CGMs in your practice, please consider participating in this educational series offered by Dexcom. It is free of charge for providers and their staff. AmeriHealth associates are always available to partner with you and your practice to improve the care for your patients with diabetes.View the schedule and register here

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