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From the desk of Mark Grippi
Market President for AmeriHealth Caritas Ohio
As one of Ohio’s newest Medicaid managed care organizations, I am excited about the opportunity that the Next Generation of Ohio Medicaid contract has created for the medical community and the Medicaid MCEs to work together to serve Ohioans! We will provide access to high-quality healthcare for our members while working in a new and different way with you, our providers. At AmeriHealth Caritas Ohio, we understand it takes all of us, working together as a system, to create positive member/patient outcomes and improve the lives of those we serve.
We are bringing collaborative communication to Ohio's managed care. My goals are to listen, communicate, and work with you. I want to be different and here’s how: tell me what you want me to know, hear, and understand. Give me guidance how to best work with you and it is my hope that we can learn from each other and keep our focus on those who need it most. Please know that AmeriHealth Caritas Ohio is heavily invested in our community and we intend to demonstrate our commitment to strong relationships. That may not mean that we always agree but we will agree to listen, learn and work for the best possible member outcomes. To that end, I look forward to seeing you in the community as well as at quarterly joint operating committee meetings, if invited. You have my written commitment to actively listen and communicate with our providers. To further that commitment, you can send me a message here.
Hopefully by now, you are familiar with AmeriHealth Caritas who is a national leader in providing managed care solutions and is one of the largest Medicaid managed care organizations in the United States. We are a mission-driven company with nearly 40 years of experience serving low-income and chronically ill populations. "Caritas" is Latin for "charity" and embodies the almost 40-year legacy of caring that AmeriHealth has established in several states, and now Ohio. Every day, we put care at the heart of our work for our members, their families, and our providers.
This monthly provider newsletter is dedicated to ensuring you have the information and assistance you need. In this issue, you’ll read about the New Provider Orientation sessions we are hosting, the latest updates from Ohio Department of Medicaid and OhioRise, and our commitment to providing timely claim payments for you.
Thank you for committing to improving health outcomes for the populations we serve in Ohio while we work better with you.
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New virtual orientation dates added for 2023
You and your office staff are invited to join us virtually for our new provider orientations. Your AmeriHealth Caritas Ohio's personal account executive looks forward to meeting you!
These orientations are designed to familiarize you with not only the vast resources available to you through our website, but also identify areas of importance to help you work with us to best serve our members — your patients.
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Virtual orientation via Zoom, 10 a.m. - 11 a.m. |
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Oct. 18 - Click here to register
Nov. 1 - Click here to register
Nov. 15 - Click here to register
Nov. 29 - Click here to register
Dec. 13 - Click here to register
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Jan. 10, 2023 - Click here to register
Jan. 24, 2023 - Click here to register
Feb. 7, 2023 - Click here to register
Feb. 21, 2023- Click here to register
Mar. 7, 2023 - Click here to register
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Welcome to our new providers!
Thank you for participating in our Ohio Medicaid health plan provider network. We would like to congratulate you on successfully completing your enrollment process. The effective date of your participation is Dec. 1 and your provider identification number will be your National Provider Identifier number (NPI). Look for your welcome packet to arrive within the next few weeks. In the meantime, you can visit our website to access:
- provider manual
- claims and billing info
- prior authorization list of services
- updates and newsletters
Your Account Executive is also available to assist you.
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For the convenience of our providers, AmeriHealth Caritas Ohio has established three Checkwrite days per week - Mondays, Wednesdays, and Fridays. We are committed to providing timely claims adjudication for you. All claims for services rendered by in-network providers must be submitted to AmeriHealth Caritas Ohio within 365 days from the actual date of service (or the date of discharge for inpatient admissions).
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Provider manual
We are pleased to have you participating in our network. Our provider manual is designed to provide important information on processes, programs and the delivery of care to AmeriHealth Caritas Ohio members. Click here to access the manual.
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New initiatives have launched! What you need to know
On October 1, Ohio Department of Medicaid (ODM) saw the launch of the Single Pharmacy Benefit Manager (SPBM) and Centralized Credentialing in the Provider Network Management (PNM) module. Since the earliest days of Governor DeWine’s administration, he asked us to listen to Ohioans and focus on each individual’s needs. To that end, we took two more big steps to honor what we heard in discussions with individuals and providers across Ohio.
➡ What can providers expect with the launch of the SPBM?
- Pharmacists and prescribers have a greater ability to monitor quality, transparency, and accountability in the pharmacy benefits program.
- The SPBM implements a single set of clinical/prior authorization policies and claims process, and serves as a single point of contact, reducing the administrative burden on providers.
- All managed care members have new Medicaid ID cards. If a member presents an old Medicaid ID card, use the Gainwell RxBIN (024251), Gainwell RxPCN (OHRXPROD), and 12-digit Ohio Medicaid Member ID (formerly MMIS ID).
➡ What can providers expect with the launch of Centralized Credentialing and PNM?
- Providers subject to credentialing can be credentialed just once at the state level versus a separate credentialing process for each Ohio Medicaid managed care plan.
- There is no longer a need for paper agreements at long-term care facilities – all agreements are available online and do not require mailing back and forth for signatures.
- Providers now can view specialties and effective dates.
➡ Ohio Medicaid has hosted a variety of provider webinars and trainings. If you missed the Next Generation of Ohio Medicaid Program Provider Overview Webinar, which reviewed the transition to the Ohio Medicaid Enterprise System (OMES) modules – including the SPBM and PNM – review the recording here. If you were unable to attend or haven’t yet viewed the trainings available for PNM or SPBM, you can find training modules, recordings, and more by visiting the Provider Webinars and Trainings webpage of the Next Generation website.
➡ Help desks are available. If you have questions related to pharmacy benefit claims, prior authorizations, and other administrative tasks, contact the Gainwell SPBM Help Desk at (833) 491-0344 or visit https://spbm.medicaid.ohio.gov.
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Reminder: New guidance for OhioRISE provider enrollment and billing effective October 1 |
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On October 1, the Ohio Department of Medicaid (ODM) launched Centralized Credentialing in the Provider Network Management (PNM) module. The PNM module replaces the Medicaid Information Technology System (MITS) and serves as a single entry point for enrollment, revalidations, credentialing, and more.
OhioRISE providers should be aware that claims and prior authorizations for a managed care organization (MCO) or Aetna, the OhioRISE plan, will continue to be submitted directly to the MCO or Aetna until the December 1 launch of the Fiscal Intermediary (FI). The launch of the FI will implement additional improvements to streamline claims processing, prior authorization requests, member eligibility requests, and claim status inquiries and attachments for providers.
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ODM has updated its guidance to help OhioRISE providers understand provider enrollment and specialty addition changes that went into effect October 1. Please view the updated OhioRISE Provider Enrollment and Billing Guidance document available on the Resources for Community Partners and Providers page of the OhioRISE webpage to learn more. Other notable changes to the guidance document include clarification around Mobile Response and Stabilization Service (MRSS) billing.
If you have questions related to Centralized Credentialing and the PNM module, please contact ODM’s Integrated Help Desk (IHD) at 800-686-1516. Provider representatives are available Monday through Friday from 8 a.m. - 4:30 p.m.
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ODM offers training ahead of launch date
In preparation for the Dec. 1 launch of the Next Generation program, the Ohio Department of Medicaid (ODM) is offering new trainings. There are self-paced, virtual and in-person sessions.
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NaviNet portal available Dec. 1
AmeriHealth Caritas Ohio is excited to announce that we are partnering with NantHealth | NaviNet. With NaviNet you will get real-time information quickly, helping to enhance office processes and minimize calls into the health plan. To get started, you can view user guides and training videos here. Details coming soon!
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Comprehensive Primary Care enrollment
Enrollment for the 2023 Comprehensive Primary Care (CPC) Program Year opened Oct. 3 and ends Oct. 31.
Invitations are being emailed to those who are eligible to participate for 2023. All enrollments and re-attestations will take place in the new Provider Network Management (PNM) Module.
CPC enrollment & re-attestation training information and resources are currently available for PNM. Enroll through Maximus’s learning managed system (LMS) called Absorb which provides self-directed, virtual and in-person trainings.
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Comprehensive Maternal Care enrollment
Enrollment for the 2023 Comprehensive Maternal Care (CMC) Program Year opened Oct. 10 and ends Nov. 7.
Invitations are being emailed to those who are eligible to participate for 2023. All enrollments and re-attestations will take place in the new Provider Network Management (PNM) Module.
CMC enrollment training information and resources are currently available for PNM. Enroll through Maximus’s learning managed system (LMS) called Absorb which provides self-directed, virtual and in-person trainings.
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Need help navigating all the changes?
Reach out to AmeriHealth Caritas Ohio provider services at 1-833-644-6001 or the Ohio Department of Medicaid provider hotline at 1-800-686-1516. We’re here to help! |
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Breast Cancer Awareness Month
Is it time to schedule your mammogram? Now is the perfect time! Women should receive a mammogram every other year beginning at age 40. Depending on your family history, your doctor may recommend that you get a mammogram even earlier. Visit cdc.gov/cancer/breast to learn more.
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Visit the Provider section of the AmeriHealth Caritas Ohio website for more information, news and resources. If you need assistance, please contact your assigned Account Executive.
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