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 toneeded services and supports, such as home visits. - Report of Pregnancy (ROP) (PDF)
- 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 Contract Inquiry 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)
| Name of policy and link | Implementation date | Post date | Updated date | Status |
|---|---|---|---|---|
| Acupuncture (PDF) | 11/15/2022 | 2/1/2023 (Posted for Go Live) | 11/14/23 | Active |
| Add-On Codes (PDF) | 1/1/2023 | 2/1/2023 (Posted for Go Live) | Active | |
| Ambulance Services (PDF) | 3/14/2023 | 7/18/2023 | Active | |
| Assistant Surgeon (PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Bilateral Procedures (PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Chronic Pain Management (PDF) | 5/9/2023 | 6/14/2023 | Active | |
| Co-Surgeon (PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Diagnosis Code Guidelines (PDF) | 3/14/2023 | 2/1/2023 (Posted for Go Live) | 3/14/23 | Active |
| Diagnosis/Procedure Code Gender Guidelines (PDF) | 2/14/2023 | 2/1/2023 (Posted for Go Live) | Active | |
| Dialysis Services (Facility) (PDF) | 7/11/2023 | 7/25/2023 | Active | |
| Discontinued Procedure (Modifier 53) (PDF) | 11/15/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Distinct Procedural Service (Modifier 59, X{EPSU}) (PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Duplicate Claim (PDF) | 11/15/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Frequency (PDF) | 4/11/2023 | 5/23/2023 | Active | |
| Federally Qualified Health Center (PDF) | 2/14/2023 | 2/1/2023 (Posted for Go Live) | Active | |
| Global Surgical Package (PDF) | 12/13/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Inappropriate Diagnosis Codes (PDF) | 9/12/2023 | 9/29/2023 | Active | |
| Maximum Units (PDF) | 4/11/2023 | 5/23/2023 | Active | |
| Medicaid Reimbursement Policy Overview (PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Medically Unlikely Edit (MUE) (PDF) | 4/11/2023 | 5/23/2023 | Active | |
| Multiple Procedure Payment Reduction (PDF) | 3/14/2023 | 7/18/2023 | Active | |
| National Correct Coding Initiative (NCCI) (PDF) | 7/11/2023 | 7/25/2023 | Active | |
| New Patient Visit (PDF) | 9/12/2023 | 10/3/2023 | Active | |
| Once-Per-Lifetime Procedures (PDF) | 11/15/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Significant-Separately Identifiable Evaluation and Management Service (Modifier 25)(PDF) | 12/1/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Team Surgery (PDF) | 3/14/2023 | 7/18/2023 | Active | |
| Telehealth (PDF) | 11/15/2022 | 2/1/2023 (Posted for Go Live) | Active | |
| Vitamin D Testing (PDF) | 9/12/2023 | 9/29/2023 | Active |