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 MITS Managed 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 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 should log in to Change Healthcare using the tool called ConnectCenter to improve claims management functionality. Providers who have a limited ability to submit claims through their hospital or project management system may now benefit from key features of the ConnectCenter tool. There is no cost to providers to use ConnectCenter.

Key features are:

      • Claims users do not need to choose between data entry of claims and upload of 837 files. All users may do both.
      • Secondary and tertiary claims can be submitted.
      • Institutional claims are supported.
      • Claims created online are fully validated in real time so that providers can correct them immediately.
      • Whether providers upload their claims or create them online, the claim reports are integrated with the claim correction screen for ease in follow-up.
      • Dashboard and work list views enable providers to streamline their billing to-do list.
      • Remittance Advice is automatically linked to a provider's submitted claim, providing a comprehensive view of the status of their claim.
      • Electronic medical attachments can be submitted using the Medical Attachment Portal. Get more information or support with this new feature on Change Healthcare's website.

To register for ConnectCenter, visit ConnectCenter Sign-Up. If you need assistance, Change Healthcare customer support is available through online chat or by phone at 1-800-527-8133, option 2.

  • Submit a 275 claim attachment transaction

AmeriHealth Caritas Ohio is accepting ANSI 5010 ASC X12 275 unsolicited attachments via Change Healthcare. 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 three ways that 275 attachments can be submitted.

  • 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.
  • Portal — individual providers can register at Change Healthcare to submit attachments.

The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, xml, doc, and txt. View the Change Healthcare 275 claims attachment transaction video for detailed instructions on this new process.

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 type Claim assignment attachment report code
Itemized bill 03
Medical records for HAC review M1
Single case agreement (SCA)/LOA 04
Advance beneficiary notice (ABN) 05
Consent form CK
Manufacturer suggested retail price/invoice 06
Electric breast pump request form 07
CME checklist consent forms (child medical eval) 08
EOBs — for 275 attachments, should only be used for non-covered or exhausted benefit letter EB
Certification of the Decision to Terminate Pregnancy CT
Ambulance trip notes/run sheet AM

If you are not a NaviNet user, sign up for NaviNet here. You will need your practice name, NPI number, and services location. 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.

Claims payment schedule

  • Medical payment cycles run every Monday, Wednesday, and Friday.

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:

ECHO claims payment schedule

  • Medical payment cycles run every Monday, Wednesday, and Friday.
  • Pharmacy payment cycles run every four days.

Electronic remittance advice (ERA) or 835 transmissions

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

All Change Healthcare/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 Change Healthcare 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 you continue to reconcile manually, and you would like to start receiving ERAs only, please contact the ECHO Health Enrollment team at 1-888-834-3511.

For enrollment support, please contact ECHO Health, Inc. 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: With the claim adjustment inquiry function
  • 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

User Guide links

Providers