AmeriHealth Caritas

AmeriHealth Caritas

AmeriHealth Caritas Family of Companies

AmeriHealth Caritas Medicaid MCO provider guide for behavioral health — credentialing, VOB, prior authorization, billing across its multi-state footprint.

Quick Reference

Payer Type

Medicaid MCO

Parent Company

AmeriHealth Caritas Family of Companies (jointly owned by Independence Health Group and Blue Cross Blue Shield of Michigan)

Headquarters

Newtown Square, PA

Provider Portal

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Portal Guide

View Guide →

Credentialing

CAQH ProView plus state Medicaid enrollment

Timeline

60-120 days

Coverage

11 states

Last Verified

Apr 19, 2026

Published

Apr 19, 2026

Reading Time

9 min

Covered Levels of Care

• Medically Managed Detoxification
• Residential Treatment (state-dependent via 1115 SUD waivers)
• Partial Hospitalization (PHP)
• Intensive Outpatient (IOP)
• Outpatient Treatment
• Crisis Stabilization and Mobile Crisis
• Medication-Assisted Treatment (MAT)
• Peer Support and Recovery Services

Medical Necessity Criteria

• State-Specific Medicaid Guidelines
• ASAM Criteria (for SUD level of care determinations)
• State-adopted mental health criteria (LOCUS, CALOCUS, or equivalent)

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Overview

AmeriHealth Caritas is one of the largest Medicaid managed care organizations in the United States, headquartered in Newtown Square, Pennsylvania. The AmeriHealth Caritas Family of Companies operates as a joint venture owned by Independence Health Group (parent of Independence Blue Cross) and Blue Cross Blue Shield of Michigan, and serves members through state-specific subsidiary plans. Over several decades, the organization has grown from a single Pennsylvania Medicaid plan into a multi-state footprint concentrated in the Mid-Atlantic, Gulf Coast, and Midwest.

AmeriHealth Caritas operates Medicaid managed care plans in the District of Columbia, Delaware, Florida, Indiana, Louisiana, Michigan, North Carolina, New Hampshire, Ohio, Pennsylvania, and South Carolina. The company also administers Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) in several of those markets for members who qualify for both Medicaid and Medicare. In Pennsylvania, plans operate under names including Keystone First, AmeriHealth Caritas Pennsylvania, and PerformCare; in South Carolina under Select Health of South Carolina; and in Louisiana as AmeriHealth Caritas Louisiana. Providers contracting across multiple states should expect brand and workflow variation even though the parent organization is the same.

For behavioral health treatment providers, AmeriHealth Caritas is particularly significant in opioid-crisis states — Pennsylvania, Ohio, Louisiana, and West Virginia-adjacent markets — where state Medicaid programs have directed substantial SUD block-grant and State Opioid Response (SOR) funding through managed care organizations. Providers working with the plan should become fluent in state-specific Medicaid rules, the SUPPORT Act requirements around MAT coverage, and any applicable Section 1115 SUD waiver provisions.

Behavioral Health Coverage

AmeriHealth Caritas covers behavioral health services as defined by each state’s Medicaid program. Commonly covered services across state plans include outpatient individual, group, and family therapy; psychiatric evaluation and medication management; intensive outpatient programs (IOP); partial hospitalization programs (PHP); crisis stabilization and mobile crisis response; medication-assisted treatment for opioid and alcohol use disorders; and peer support and recovery services. Many state plans also cover assertive community treatment (ACT), targeted case management, and psychosocial rehabilitation.

Residential SUD treatment coverage depends on the state’s Section 1115 SUD demonstration waiver status. The federal IMD exclusion historically prohibited Medicaid payment for services delivered in institutions for mental diseases with more than 16 beds. However, most AmeriHealth Caritas states have secured 1115 waivers that allow short-term residential SUD stays — typically up to 30 days per episode — in qualifying facilities. The SUPPORT for Patients and Communities Act of 2018 further codified state flexibility to cover MAT and certain institutional SUD services. Confirm your state’s waiver status and any length-of-stay limits in the current state-specific provider manual before admitting Medicaid members to a residential program.

For members under age 21, AmeriHealth Caritas covers behavioral health services consistent with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. EPSDT requires state Medicaid programs and their MCOs to cover any medically necessary service to correct or ameliorate a physical or mental condition, even if that service is not otherwise included in the state plan. In practice, this means that residential, wraparound, and intensive community-based services for adolescents are generally covered when clinically justified, and medical necessity reviews must apply the broader EPSDT standard rather than adult benefit limits.

Medical necessity is evaluated using the ASAM Criteria for substance use disorder placements and state-adopted criteria (such as LOCUS, CALOCUS, or state-specific tools) for mental health services. Clinical documentation should align explicitly with the criteria adopted in your state — a common denial driver is documentation that references national criteria while the state has adopted a different framework.

Credentialing and Provider Enrollment

AmeriHealth Caritas uses CAQH ProView as its primary credentialing data source across all state plans. Before applying, ensure every individual clinician and your facility have fully attested CAQH profiles with current licensure, NPI and taxonomy information, malpractice coverage, accreditation certificates, and service-location details.

State Medicaid enrollment is almost always a prerequisite to contracting with AmeriHealth Caritas. In Pennsylvania, providers must be enrolled through PROMISe; in Ohio, through the Ohio Department of Medicaid Provider Network Management module; in Louisiana, through the Louisiana Medicaid Provider Enrollment portal; and analogous processes exist in every other state. Begin state Medicaid enrollment early, as it can add weeks to months to the overall timeline. In a few states, the MCO can initiate credentialing in parallel, but claims will not pay until state Medicaid enrollment is complete.

Facility-level credentialing requires state behavioral health facility licensure, accreditation by Joint Commission, CARF, COA, or a state-recognized body, an organizational NPI, general and professional liability coverage at contracted limits, and a current W-9. AmeriHealth Caritas may require a site visit for residential and crisis facilities. After a complete application is received, credentialing typically takes 60 to 120 days. Recredentialing occurs on a standard three-year cycle, and lapses can result in claims being held or denied.

Verification of Benefits (VOB)

Verifying eligibility for AmeriHealth Caritas members is a two-step process that differs from commercial payer workflows. First, confirm active Medicaid enrollment and MCO assignment through the state Medicaid eligibility portal — for example, PROMISe in Pennsylvania, Medicaid.ohio.gov in Ohio, the LaMedicaid portal in Louisiana, or NC Tracks in North Carolina. This step is non-negotiable: if the state portal shows the member is not enrolled on the date of service or is assigned to a different MCO, AmeriHealth Caritas will not pay the claim regardless of what its own portal shows.

Second, verify plan-specific behavioral health benefits through the AmeriHealth Caritas provider portal hosted on NaviNet (navinet.navimedix.com). The portal provides covered services, authorization requirements, benefit limits, and primary care provider assignment. For detailed behavioral health VOB, particularly for facility-based services or complex cases, contact the state-specific provider services line listed on the member’s insurance card or in the state provider manual.

Medicaid eligibility can change monthly based on redetermination, income changes, or coverage transitions. Re-verify eligibility on or near every date of service. Because Medicaid is the payer of last resort, also screen for commercial, Medicare, TRICARE, or VA coverage that would take primary position. Document each VOB with date, representative name, reference number, and the specific benefits and authorization requirements confirmed.

Prior Authorization Requirements

AmeriHealth Caritas generally requires prior authorization for residential SUD treatment (where covered), medically managed detoxification, inpatient psychiatric hospitalization, partial hospitalization, and some intensive outpatient programs. Outpatient therapy and office-based MAT typically do not require PA, though a few state plans impose visit thresholds after which authorization is required.

Authorization requests are usually submitted through NaviNet, by fax, or by phone to the state-specific utilization management team — refer to the current state provider manual for the correct channel. Clinical documentation should cover diagnosis, presenting symptoms, substance use or psychiatric history, prior treatment episodes, current risk assessment, and the proposed treatment plan. For SUD requests, organize your clinical narrative around the six ASAM Criteria dimensions and state the specific level of care requested. For mental health requests, document against the state’s adopted criteria.

Concurrent reviews for residential and inpatient levels of care are typically required every 3 to 7 days depending on the state and level of care; PHP reviews usually occur every 7 to 14 days. Each review requires updated clinical documentation showing progress, continued medical necessity, and active discharge planning. If continued-stay authorization is denied, request a peer-to-peer review with the AmeriHealth Caritas medical director before filing a formal appeal — many denials are resolved through peer-to-peer discussion.

Claims and Billing

AmeriHealth Caritas accepts electronic claims through EDI 837I (institutional, UB-04) and 837P (professional, CMS-1500) via clearinghouses, as well as through the NaviNet provider portal. Electronic submission is strongly preferred for faster processing. Confirm the correct payer ID for each state plan with your clearinghouse — Keystone First, AmeriHealth Caritas Pennsylvania, Select Health of South Carolina, and other subsidiaries have distinct payer IDs.

Billing codes, modifiers, and reimbursement rates follow each state’s Medicaid fee schedule and the AmeriHealth Caritas provider contract. Use state-specific codes such as SUD H-codes, EPSDT modifiers for members under 21, and any required place-of-service or taxonomy details. State provider manuals publish current fee schedules and billing guides — review them before submitting high-dollar facility claims.

Timely filing windows are set by each state Medicaid contract, not by AmeriHealth Caritas corporate policy. Common deadlines range from 95 to 180 days from date of service, with a few states allowing up to 365 days. Corrected claims and coordination-of-benefits submissions usually have their own windows. Late-filed Medicaid claims have limited appeal rights, so build timely filing alerts into your workflow.

Common denial reasons include absence of required prior authorization, member not enrolled or assigned to a different MCO on the date of service, incorrect diagnosis codes, non-covered services, duplicate claims, and third-party liability issues. Track denial reason codes to identify systemic issues. File corrected claims for billing errors and formal appeals for clinical denials within the deadlines specified in the state provider manual.

Key Contact Information

State plans include (each with its own provider manual): Keystone First (PA), AmeriHealth Caritas Pennsylvania, AmeriHealth Caritas DC, AmeriHealth Caritas Delaware, AmeriHealth Caritas Florida, AmeriHealth Caritas Next (IN / NC / NH), AmeriHealth Caritas Louisiana, AmeriHealth Caritas Ohio, AmeriHealth Caritas VIP Care (Medicare), Select Health of South Carolina, and the Michigan joint-venture plan.

• Provider Portal: NaviNet — https://navinet.navimedix.com ↗ (primary provider transaction platform for all AmeriHealth Caritas plans)
• Credentialing: CAQH ProView ( https://proview.caqh.org ↗ ) plus state Medicaid enrollment; contact the AmeriHealth Caritas state-specific provider enrollment team to initiate
• Prior Authorization: Submit through NaviNet, fax, or the state-specific UM phone line listed in the current provider manual
• Verification of Benefits: Two-step — state Medicaid portal plus NaviNet; for detail, call the state-specific provider services line on the member’s ID card
• Claims Submission: Electronic 837I / 837P via clearinghouse (state-specific payer IDs) or NaviNet
• State-Specific Provider Manuals: Available in the “Providers” section of each state plan’s website, linked from amerihealthcaritas.com

Frequently Asked Questions

State Medicaid fee-for-service enrollment is almost always a prerequisite for joining an AmeriHealth Caritas Medicaid MCO network, but it is not a substitute. After completing state Medicaid enrollment, maintain a current, fully attested CAQH ProView profile and submit a separate AmeriHealth Caritas participation request for each state plan you want to join. The plans operate under different names in different states — for example, Keystone First in southeast Pennsylvania, AmeriHealth Caritas Louisiana, and Select Health of South Carolina — and each has its own contract, credentialing committee, and provider manual. Credentialing typically takes 60 to 120 days from receipt of a complete application.

Residential SUD coverage depends on whether the state has an active Section 1115 SUD demonstration waiver that permits Medicaid payment for services in institutions for mental diseases (IMDs) with more than 16 beds. Several AmeriHealth Caritas states — including Pennsylvania, Louisiana, North Carolina, and New Hampshire — operate with approved SUD waivers, and AmeriHealth Caritas funds residential levels of care there subject to ASAM Criteria and state-specific length-of-stay limits. In states without an active waiver or for facilities exceeding the size threshold, Medicaid payment for residential treatment may be restricted. Always confirm facility eligibility and authorization rules in the current state-specific provider manual before admitting a member.

AmeriHealth Caritas generally covers all three FDA-approved MAT medications (buprenorphine, methadone, and naltrexone) in line with the federal SUPPORT for Patients and Communities Act, which requires state Medicaid programs to cover MAT. Office-based buprenorphine and oral naltrexone typically do not require prior authorization, while long-acting injectable formulations, opioid treatment program (OTP) services, and certain office-based methadone arrangements may. Many plans waive PA for the first stabilization period to reduce barriers to care. Bill OTP encounters using HCPCS bundled codes where required by the state and coordinate closely with the state Medicaid pharmacy benefit for medication claims.

Medicaid eligibility is determined monthly by the state Medicaid agency, not by AmeriHealth Caritas. You must verify eligibility in two places: the state Medicaid portal (for example, PROMISe in Pennsylvania or Medicaid.ohio.gov in Ohio) to confirm active Medicaid enrollment and MCO assignment, and the AmeriHealth Caritas provider portal on NaviNet to confirm plan-specific benefits, covered services, and any authorization requirements. Check eligibility at admission and again at monthly re-verification. Because Medicaid is the payer of last resort, also screen for other insurance; any commercial or Medicare coverage must be billed first before AmeriHealth Caritas pays.

Timely filing limits are set by each state Medicaid contract, not by AmeriHealth Caritas corporate policy. Common windows range from 95 days to 180 days from date of service for initial claims, with some states allowing up to 365 days. Corrected claims and claims with coordination-of-benefits adjustments usually have a separate, often shorter, window measured from the primary payer's determination date. The exact deadline is stated in the state-specific provider manual — always reference the current manual rather than relying on a general rule. Late Medicaid claims have very limited appeal rights, so build timely filing alerts into your revenue cycle workflow.

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