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 members 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 Department of Job and Family Services office.
• Report of Pregnancy (ROP) Submission and Billing Instructions for Doulas (PDF)
  
• Substance Use Disorder Residential Treatment Notification of Admission (PDF)
• Substance Use Disorder Services Prior Authorization 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.