Claims and Billing

NO PAPER CLAIMS reminder:

The Next Generation of Ohio Medicaid program's guidelines require all claims to be submitted via the Electronic Data Exchange (EDI). Use AmeriHealth Caritas Ohio’s EDI Payer ID#: 35374.

 

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ODM quick reference: Points of submission for claims and prior authorizations

 Provider Network Management (PNM) via a link to MITSManaged Care Portals*Electronic Data Interchange (EDI) via a trading partner
Managed care claims✗ No✓ Yes✓ Yes
Managed care prior authorizations**✗ No✓ Yes✗ No
Fee-for-service claims✓ Yes✗ No✓ Yes
Fee-for-service prior authorizations✓ Yes✗ No✗ No

*ODM is working with the Managed Care Entities (MCEs) to share data for claims and prior authorizations that are submitted directly to the MCOs (not through PNM or EDI).

**Managed Care prior authorizations are to be submitted via MCE guidance, which may include portal entry or other electronic processes.

Visit the ODM Provider Network Management System webpage.

Claims

  • EDI: Providers with electronic data interchange (EDI) capabilities may submit claims, eligibility inquiries, claim status inquiries, and associated attachments by being a trading partner authorized by ODM or by contracting with an ODM-authorized trading partner. For more information, visit the ODM trading partners webpage or call the ODM IHD at 1-800-686-1516.
  • DDE: For Direct Data Entry (DDE), providers may submit manual/direct data entry claims via:
    • Optum/Change Healthcare ConnectCenter. Access the portal via the Claims submission link in the NaviNet provider portal or visit ConnectCenter to complete your provider registration.

      Note:       this URL is specific to new provider registration only. If you need assistance, Optum/Change Healthcare customer support is available through online chat or by phone at 1-800-527-8133, option 2.
  • If you are not a NaviNet user, sign up for NaviNet. You will need your practice name, Tax Identification Number (TIN), phone number, and services location. You will also be asked to attach one of the following documents for verification: Certificate of Good Standing, Sole Proprietor SS-4, or IRS 147C Letter. Make sure to complete all information requested. You will be able to access the AmeriHealth Caritas Ohio information and any specific data for your practice. If you need more information or assistance, call NaviNet at 1-888-482-8057.
  • PCH Global — providers not currently using PCH Global must enroll for claims submission with PCH Global.

Submit a 275 claim attachment transaction

AmeriHealth Caritas Ohio is accepting ANSI 5010 ASC X12 275 unsolicited attachments via Optum/Change Healthcare and Availity. Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 attachment submissions via payer ID 35374.

There are two ways that 275 attachments can be submitted:

Optum/Change Healthcare

  • Batch — you may either connect to Change Healthcare directly or submit via your EDI clearinghouse.
  • API via JSON — you may submit an attachment for a single claim.

Availity

  • Batch — you may either connect to Availity directly or submit via your EDI clearinghouse.
  • Portal — individual providers may also register with Availity to submit attachments.

After logging in, providers registered with Availity may access the Attachments — Training Demo for detailed instructions on the submission process or refer to the Availity Claims Attachment Quick Reference Guide (PDF) located under Claim resources at the bottom of this page.

General guidelines

  • A maximum of 10 attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100 MB.
  • The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
  • The 275 attachments must be submitted prior to the 837. After successfully submitting a 275 attachment, an Attachment Control Number will generate. The Attachment Control Number must be submitted in the 837 transactions as follows:
    • CMS 1500
      • Field Number 19
      • Loop 2300
      • PWK segment
    • UB-04
      • Field Number 80
      • Loop 2300
      • PWK01 segment

In addition, the following 275 claims attachment report codes have been added. When submitting an attachment, use the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the Claims Filing Instructions (PDF).

Attachment typeClaim assignment attachment report code
Itemized bill03
Medical records for HAC reviewM1
Single case agreement (SCA)/LOA04
Advance beneficiary notice (ABN)05
Consent formCK
Manufacturer suggested retail price/invoice06
Electric breast pump request form07
CME checklist consent forms (child medical eval)08
EOBs — for 275 attachments, should only be used for non-covered or exhausted benefit letterEB
Certification of the Decision to Terminate PregnancyCT
Ambulance trip notes/run sheetAM

Electronic funds transfer (EFT)

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).

How to enroll

If you already receive payments from ECHO Health, you may be able to enroll for EFT with AmeriHealth Caritas Ohio using your existing account. Please make sure you have an ECHO Health draft number and corresponding payment amount so your enrollment request can be validated. A draft number is listed as the EPC draft number on ECHO Health's explanation of payments. If you need assistance locating an ECHO payment in order to register, you can contact ECHO at 1-800-946-4041 Monday – Friday from 8 a.m. – 6 p.m. ET.

If you have never received an EFT payment through ECHO Health for any payer, please use the fillable form linked below to complete your registration. It will be helpful to use the ERA/EFT Supplemental Guide to walk you through the steps on the form.

When you complete the form, you may submit it using any of the following options:

Electronic remittance advice (ERA) or 835 transmissions

AmeriHealth Caritas Ohio offers ERAs (also referred to as an 835 file) through ECHO Health, Inc. If you would like to receive ERAs from ECHO, you will need to include both the AmeriHealth Caritas Ohio payer ID 35374 and the ECHO payer ID 58379.

All ECHO Health-generated ERAs and a detailed explanation of payment for each transaction will be accessible to download from the ECHO provider portal. If you are a first-time user and need to create a new account, please reference ECHO Health's Provider Payment Portal Quick Reference Guide (PDF) for instructions.

Contact your practice management/hospital information system for instructions on how to receive ERAs from AmeriHealth Caritas Ohio under Payer ID 35374 and the ECHO Payer ID 58379. If your practice management/hospital information system is already set up and can accept ERAs from AmeriHealth Caritas Ohio, then it is important to check that the system includes the AmeriHealth Caritas Ohio payer ID 35374 and the ECHO Health payer ID 58379 for ERAs.

If you are not receiving any payer ERAs, please contact your current practice management/hospital information system vendor to inquire if your software has the ability to process ERAs. Your software vendor is then responsible for contacting ECHO to enroll for ERAs under AmeriHealth Caritas Ohio Payer ID 35374 and ECHO Health Payer ID 58379.

If your software does not support ERAs, or if you continue to reconcile manually, and you would like to start receiving ERAs only or need additional enrollment support, please contact the ECHO Health Enrollment team at 1-888-834-3511.

If you have additional questions regarding EFT or ERAs, please call the ECHO Health Support team at 1-888-492-5579 or refer to ECHO Payments Frequently Asked Questions (PDF).

Electronic visit verification (EVV)

The Ohio Department of Medicaid (ODM) uses electronic visit verification for some home- and community-based services. EVV is an electronic system that verifies key information about the provision of these services. EVV requirements apply to both agency and non-agency providers of these services. This work meets requirements in the Federal 21st Century Cures Act. For more information on EVV, visit ODM’s website. 

Provider Dispute Submission Form

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. A dispute can be submitted 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)
  • NaviNet: via Submit Provider Dispute form under Forms and Dashboards 
  • Mail:
    AmeriHealth Caritas Ohio
    Attn: Provider Claim Inquiry
    P.O. Box 7126
    London, KY 40742
  • Fax: 1-833-216-2272

Provider Appeal Form

Providers may file an appeal on a denied pre-service within 30 days of the notice of Adverse Benefit Determination (ABD).

  • Mail with supporting documentation to:
    AmeriHealth Caritas Ohio
    Provider Appeals
    P.O. Box 7400
    London, KY 40742
  • Fax: 1-833-564-1329

Claim resources

ConnectCenter User Guide links

If you need more information or can't find an answer to your question, check your provider manual (PDF). You can also call AmeriHealth Caritas Ohio Provider Services at 1-833-644-6001.