Provider Manuals, Policies, and Forms

Manuals and guides

AmeriHealth Caritas Ohio offers these reference materials to our providers for use when treating our members.

• Provider manual (PDF)
  This manual will help you and your office staff provide services to our members.

If you have any questions, call Provider Services at 1-833-644-6001, or contact your Provider Services Account Executive.

Forms

Ohio Department of Medicaid forms

• Abortion Certification (PDF)
• Acknowledgment of Hysterectomy Information (PDF)
• Aceptación de la Información Sobre Histerectomia (PDF)
• Consent for Sterilization (PDF)
• Consentimiento Para La Esterilización (PDF)
• External Medical Review (EMR) process FAQ (PDF)
• Healthchek and Pregnancy Related Services Information Sheet (PDF)
• Medicaid Advisory Letter and Attestation (PDF)
• Ohio PCP change form (PDF)
• Pregnancy Risk Assessment Communication (PRAF) (PDF)
  

  Submit this form to assist pregnant women in maintaining Medicaid eligibility and to connect them to

  needed services and supports, such as home visits.

• Report of Pregnancy (ROP) (PDF)
• Report of Pregnancy (ROP) Submission and Billing Instructions (PDF)
  If unable to submit electronically, mail or fax the form to the member's local county JFS office.
• Substance Use Disorder Residential Treatment Notification of Admission (PDF)
• Substance Use Disorder Services Prior Auth Request (PDF)

AmeriHealth Caritas Ohio forms

• Prior Authorization Request form (PDF)
• Physician Administered Medication Prior Authorization Request form (PDF)
• Behavioral Health Prior Authorization Form (PDF)
• Provider Appeal Submission Form (PDF)
• Provider Contract Inquiry Form (PDF)
• Provider Dispute Submission Form (PDF)
• Comprehensive Primary Care (CPC) Program Addendum (PDF)

Transportation forms

• Non-Emergency Medical Transportation Ohio Facility Direct Scheduling Option Affidavit (PDF)
• Ohio Non-Emergency Medical Transportation Facility Direct Scheduling Option for Transportation Providers (PDF)

Reimbursement/Payment Policies

• Clinical Coverage Policies
• Clinical Practice Guidelines
• Diabetes Self-Management Education (DSME) Enhanced Reimbursement Rates (PDF)
• Reimbursement Policies

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.