Provider and Billing Manual · • Notify the Medical Management department of all newborn deliveries within one day of the delivery; notification may occur by our Secure Provider - [PDF Document] (2024)

  • Provider and Billing Manual2021

    Ambetter.SunshineHealth.comAMBPROV20-FL-C-00024 © 2020 CelticInsurance Company. All rights reserved.

  • Table of ContentsWELCOME 7

    HOW TO USE THIS PROVIDER MANUAL--------------------------------------------------------------------------------------------------------------------------


    NONDISCRIMINATION OF HEALTH CARE SERVICE DELIVERY --------- 9KEYCONTACTS AND IMPORTANT PHONE NUMBERS ------------------ 10SECUREPROVIDER PORTAL-----------------------------------------------------12Functionality---------------------------------------------------------------------------------------------------------------------



    CREDENTIALING AND RECREDENTIALING---------------------------------- 13Eligible Providers--------------------------------------------------------------------------------------------------------------14

    Non Registered CAQH Providers-----------------------------------------------------------------------------------------14

    Credentialing Committee----------------------------------------------------------------------------------------------------14


    Practitioner Right to Review and Correct Information-------------------------------------------------------------15

    Practitioner Right to Be Informed of Application Status---------------------------------------------------------- 15

    Practitioner Right to Appeal or Reconsideration of AdverseCredentialing Decisions ----------------- 15

    PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER --------17Provider Types That May Serve As PCPs------------------------------------------------------------------------------17

    Withdrawing from Caring for a Member--------------------------------------------------------------------------------18

    PCP Coordination of Care to Specialists-------------------------------------------------------------------------------18

    Appointment Availability and Wait Times------------------------------------------------------------------------------19

    Travel Distance and Access Standards--------------------------------------------------------------------------------19

    Covering Providers------------------------------------------------------------------------------------------------------------20

    Provider Phone Call Protocol----------------------------------------------------------------------------------------------20

    Provider Data Updates and Validation----------------------------------------------------------------------------------20

    Hospital Responsibilities----------------------------------------------------------------------------------------------------21

    AMBETTER BENEFITS---------------------------------------------------------------22Overview--------------------------------------------------------------------------------------------------------------------------22

    Additional Benefit Information--------------------------------------------------------------------------------------------23

    Integrated Deductible Products-------------------------------------------------------------------------------------------23

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  • January 12, 2021 2

    Non- Integrated Deductible Products-----------------------------------------------------------------------------------24

    Maximum Out-of-pocket Expenses--------------------------------------------------------------------------------------24

    Free Visits------------------------------------------------------------------------------------------------------------------------25

    Covered Services--------------------------------------------------------------------------------------------------------------25

    Notification of Pregnancy---------------------------------------------------------------------------------------------------26

    Adding a Newborn or an Adopted Child--------------------------------------------------------------------------------26

    Non-Covered Services-------------------------------------------------------------------------------------------------------26

    Transplant Services-----------------------------------------------------------------------------------------------------------26

    Tribal Provider (AIAN) American Indian Alaska Native------------------------------------------------------------ 27

    MEMBER BENEFITS, MEMBER IDENTIFICATION CARD, ELIGIBILITY, ANDCOST SHARES------------------------------------------------------------------29 Member Benefits---------------------------------------------------------------------------------------------------------------29

    Member Identification Card-------------------------------------------------------------------------------------------------29

    Preferred Method to Verify Benefits, Eligibility, and CostShares --------------------------------------------- 29

    Other Methods to Verify Benefits, Eligibility and Cost Shares-------------------------------------------------- 30

    Importance of Verifying Benefits, Eligibility, and Cost Shares------------------------------------------------- 31

    MEDICAL MANAGEMENT----------------------------------------------------------- 32Utilization Management------------------------------------------------------------------------------------------------------32

    Medically Necessary----------------------------------------------------------------------------------------------------------32

    Timeframes for Prior Authorization Requests and Notifications----------------------------------------------- 32

    Utilization Determination Timeframes----------------------------------------------------------------------------------33

    Services Requiring Prior Authorization--------------------------------------------------------------------------------33

    Procedure for Requesting Prior Authorizations---------------------------------------------------------------------34

    Care Management and Concurrent Review---------------------------------------------------------------------------40

    Health Management-----------------------------------------------------------------------------------------------------------41

    Ambetter’s My Health Pays Member Rewards Program---------------------------------------------------------- 42

    CLAIMS------------------------------------------------------------------------------------43 Verification Procedures------------------------------------------------------------------------------------------------------43

    Upfront Rejections vs. Denials--------------------------------------------------------------------------------------------45

    Timely Filing---------------------------------------------------------------------------------------------------------------------45

    Refunds and Overpayments------------------------------------------------------------------------------------------------45

    Who Can File Claims?--------------------------------------------------------------------------------------------------------46

    Electronic Claims Submission--------------------------------------------------------------------------------------------46

  • January 12, 2021 3

    Online Claim Submission---------------------------------------------------------------------------------------------------49

    Paper Claim Submission----------------------------------------------------------------------------------------------------50

    Electronic Funds Transfers (EFT) and Electronic RemittanceAdvices (ERA) ----------------------------- 51

    Corrected Claims, Requests for Reconsideration or Claim Disputes---------------------------------------- 52

    Risk Adjustment and Correct Coding-----------------------------------------------------------------------------------54

    Claim Reconsiderations Related To Code Editing And Editing------------------------------------------------ 59

    CODEEDITING--------------------------------------------------------------------------60 CPT and HCPCS Coding-----------------------------------------------------------------------------------------------------60

    International Classification of Diseases (ICD-10)-------------------------------------------------------------------61

    Revenue Codes-----------------------------------------------------------------------------------------------------------------61

    Edit Sources---------------------------------------------------------------------------------------------------------------------61

    Code Editing Principles------------------------------------------------------------------------------------------------------62

    Invalid Revenue to Procedure Code Editing--------------------------------------------------------------------------64

    Inpatient Facility Claim Editing--------------------------------------------------------------------------------------------65

    Administrative and Consistency Rules---------------------------------------------------------------------------------66

    Prepayment Clinical Validation--------------------------------------------------------------------------------------------66

    Claim Reconsiderations Related To Code Editing------------------------------------------------------------------68

    Viewing Claims Coding Edits----------------------------------------------------------------------------------------------69

    Automated Clinical Payment Policy Edits-----------------------------------------------------------------------------69

    Clinical Payment Policy Appeals-----------------------------------------------------------------------------------------70

    THIRD PARTY LIABILITY------------------------------------------------------------ 71BILLING THE MEMBER-------------------------------------------------------------- 72Covered Services--------------------------------------------------------------------------------------------------------------72

    Non-Covered Services-------------------------------------------------------------------------------------------------------72

    Premium Grace Period for Members Receiving Advanced Premium TaxCredits (APTCs) ----------- 73

    Failure to Obtain Authorization-------------------------------------------------------------------------------------------73

    No Balance Billing-------------------------------------------------------------------------------------------------------------73

    MEMBER RIGHTS AND RESPONSIBILITIES---------------------------------- 74 Member Rights------------------------------------------------------------------------------------------------------------------74

    Member Responsibilities----------------------------------------------------------------------------------------------------75

    PROVIDER RIGHTS AND RESPONSIBILITIES------------------------------- 77 Provider Rights-----------------------------------------------------------------------------------------------------------------77

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    Provider Responsibilities---------------------------------------------------------------------------------------------------77

    CULTURAL COMPETENCY--------------------------------------------------------- 80Language Services------------------------------------------------------------------------------------------------------------81

    Provider Accessibility Initiative-------------------------------------------------------------------------------------------82

    Americans with Disabilities Act (ADA)----------------------------------------------------------------------------------83

    COMPLAINT PROCESS-------------------------------------------------------------- 86Complaint/Grievance---------------------------------------------------------------------------------------------------------86

    Provider Complaint/Grievance and Appeal Process---------------------------------------------------------------86

    Member Appeals---------------------------------------------------------------------------------------------------------------86

    Member Complaint/Grievance and Appeal Process----------------------------------------------------------------87

    Mailing Address----------------------------------------------------------------------------------------------------------------87

    QUALITY IMPROVEMENT PLAN-------------------------------------------------- 88 Overview--------------------------------------------------------------------------------------------------------------------------88

    QAPI Program Structure-----------------------------------------------------------------------------------------------------88

    Quality Rating System-------------------------------------------------------------------------------------------------------92

    Provider Satisfaction Survey-----------------------------------------------------------------------------------------------94

    Qualified Health Plan (QHP) Enrollee Survey-------------------------------------------------------------------------94

    Provider Performance Monitoring and Incentive Programs----------------------------------------------------- 94

    REGULATORY MATTERS----------------------------------------------------------- 96Medical Records---------------------------------------------------------------------------------------------------------------96

    Medical Records Release---------------------------------------------------------------------------------------------------98

    Federal And State Laws Governing The Release Of Information---------------------------------------------- 98

    National Network---------------------------------------------------------------------------------------------------------------99

    Section 1557 of the Patient Protection and Affordable Care Act--------------------------------------------- 100

    FRAUD, WASTE AND ABUSE----------------------------------------------------- 101 FWAProgram Compliance Authority and Responsibility------------------------------------------------------ 102

    False Claims Act-------------------------------------------------------------------------------------------------------------102

    Physician Incentive Programs-------------------------------------------------------------------------------------------102

    APPENDIX-------------------------------------------------------------------------------104 Appendix I: Common Causes for Upfront Rejections----------------------------------------------------------- 104

    Appendix II: Common Cause of Claims Processing Delays andDenials---------------------------------- 105

    Appendix III: Common EOP Denial Codes and Descriptions-------------------------------------------------- 105

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    Appendix IV: Instructions for Supplemental Information------------------------------------------------------- 106

    Appendix V: Common Business EDI Rejection Codes---------------------------------------------------------- 108

    Appendix VI: Claim Form Instructions--------------------------------------------------------------------------------108

    Appendix VII: Billing Tips and Reminders---------------------------------------------------------------------------108

    Appendix VIII: Reimbursem*nt Policies------------------------------------------------------------------------------139

    Appendix IX: EDI Companion Guide Overview---------------------------------------------------------------------142

    STATE MANDATED REGULATORY REQUIREMENTS -------------------- 151Arkansas------------------------------------------------------------------------------------------------------------------------151









    North Carolina----------------------------------------------------------------------------------------------------------------164

    New Hampshire---------------------------------------------------------------------------------------------------------------169




    South Carolina----------------------------------------------------------------------------------------------------------------177



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  • WELCOME Welcome to Ambetter from Sunshine Health (“Ambetter”).Thank you for participating in our network of high qualityphysicians, hospitals, and other healthcare professionals.

    Ambetter’s Health Insurance Marketplace plans target a consumerpopulation of lower income, previously uninsured individuals andfamilies who, prior to having this health insurance, may have beenMedicaid-eligible or unable to access care due to financialchallenges.

    Partnering with Ambetter provides an opportunity for you toaccess a previously untapped consumer population by providingcoverage to those who qualify for generous premium and cost sharingsubsidies. Ambetter has been very successful in attracting andretaining our target population, and continues to focus on engagingand acquiring these subsidy-eligible consumers through its uniqueplan designs, incentive programs, and effective communication.

    Ambetter is a Qualified Health Plan (QHP) as defined in theAffordable Care Act (ACA). Ambetter is offered to consumers throughthe Health Insurance Marketplace, also known as the Exchange. TheHealth Insurance Marketplace makes buying health insuranceeasier.

    The Affordable Care Act is the law that has changed healthcare.The goals of the ACA are:

    • To help more Americans get health insurance and stayhealthy

    • To offer consumers a choice of coverage leading to increasedhealth care engagement and empowerment

    January 12, 2021 7

  • HOW TO USE THIS PROVIDER MANUALAmbetter is committed toassisting its provider community by supporting their efforts todeliver well-coordinated and appropriate health care to ourmembers. Ambetter is also committed to disseminating comprehensiveand timely information to its providers through this providermanual regarding Ambetter’s operations, policies, and procedures.Updates to this manual will be posted on our website Additionally, providers may benotified via bulletins and notices posted on the website andpotentially on Explanation of Payment notices. Providers maycontact our Provider Services department at 1-866-796-0542 torequest that a copy of this manual be mailed to you. In accordancewith the Participating Provider Agreement, providers are requiredto comply with the provisions of this manual. Ambetter routinelymonitors compliance with the various requirements in this manualand may initiate corrective action, including denial or reductionin payment, suspension, or termination if there is a failure tocomply with any requirements of this manual.

    Dental and Vision Provider Manuals

    Envolve Dental and Vision provider manuals are available on theSecure Provider Portal. Providers may visit and log on or contact us for these providermanuals.

    Ancillary Provider Manuals

    Additional provider manuals are available on the Secure ProviderPortal. Providers may visit the following and log on or contact usfor these provider manuals:

    • Envolve (RX) • RX ADvanced • Teledoc • Babylon • NIA • Evicore• Ash (AZ) • Home Town Health • Logisticare Ambulance EmergencyNon-Emergency and Non-Medical Vendor • USMM • MEDXM

    January 12, 2021 8


  • NONDISCRIMINATION OF HEALTH CARE SERVICE DELIVERY Ambettercomplies with the guidance set forth in the final rule for Section1557 of the Affordable Care Act, which includes notification ofnondiscrimination and instructions for accessing language servicesin all significant member materials and physical locations thatserve our members.

    All providers who join the Ambetter Provider Network must alsocomply with the provisions and guidance set forth by the Departmentof Health and Human Services (HHS) and the Office for Civil Rights(OCR).

    Ambetter requires providers to deliver services to Ambettermembers without regard to race, color, national origin, age,disability or sex. Providers must not discriminate against membersbased on their payment status and cannot refuse to serve based onvarying policy and practices and other criteria for the collectingof member financial responsibility from Ambetter members.

    Newborns’ and Mothers’ Health Protection Act

    The Newborns’ and Mothers’ Health Protection Act (the Newborns’Act) provides protections for mothers and their newborn childrenrelating to the length of their hospital stays followingchildbirth. Under the Newborns’ Act, group health plans may notrestrict benefits for mothers or newborns for a hospital stay inconnection with childbirth to less than 48 hours following avagin*l delivery or 96 hours following a delivery by cesareansection. The 48-hour (or 96- hour) period starts at the time ofdelivery, unless a woman delivers outside of the hospital. In thatcase, the period begins at the time of the hospital admission. Theattending provider may decide, after consulting with the mother, todischarge the mother and/or her newborn child earlier. Theattending provider cannot receive incentives or disincentives todischarge the mother or her child earlier than 48 hours (or 96hours). Even if a plan offers benefits for hospital stays inconnection with childbirth, the Newborns’ Act only applies tocertain coverage. Specifically, it depends on whether coverage is“insured” by an insurance company or HMO or “self-insured” by anemployment-based plan. (Check the Summary Plan Description, thedocument that outlines benefits and rights under the plan, orcontact the plan administrator to find out if coverage inconnection with childbirth is “insured” or “self-insured.”) TheNewborns’ Act provisions always apply to coverage that isself-insured. If the plan provides benefits for hospital stays inconnection with childbirth and is insured, whether the plan issubject to the Newborns’ Act depends on state law. Many states haveenacted their own version of the Newborns’ Act for insuredcoverage. If your state has a law regulating coverage for newbornsand mothers that meets specific criteria and coverage is providedby an insurance company or HMO, state law will apply. All grouphealth plans that provide maternity or newborn infant coverage mustinclude in their Summary Plan Descriptions a statement describingthe Federal or state law requirements applicable to the plan (orany health insurance coverage offered under the plan) relating tohospital length of stay in connection with childbirth for themother or newborn child.

    January 12, 2021 9

  • KEY CONTACTS AND IMPORTANT PHONE NUMBERS The following tableincludes several important telephone and fax numbers available toproviders and their office staff. When calling, it is helpful tohave the following information available:


    The provider’s NPI number

    2. The practice Tax ID Number

    3. The member’s ID number


    Ambetter from Sunshine Health

    Ambetter from Sunshine Health 1700 N. University Dr. Plantation,FL 33322

    1-877-687-1169 (Relay Florida 1-800-955-8770) Relay:1-800-955-8770

    Department Phone Fax/Web Address

    Provider Services

    1-877-687-1169 (Relay Florida 1-800-955-8770)


    Member Services 1-866-796-0526

    Medical Management Inpatient and Outpatient PriorAuthorization


    Concurrent Review/Clinical Information 1-866-550-3290

    Admissions/Census Reports/ Facesheets 1-877-243-3240

    Care Management 1 -877-689-1056 Behavioral Health PriorAuthorization - Outpatient 1 -844-208-9113

    Behavioral Health Prior Authorization – Inpatient DischargeSummaries


    Behavioral Health Prior Authorization – Inpatient (SUD PHP /RTC)


    24/7 Nurse Advice Line NA

    Pharmacy Solution 1-866-399-0929

    Advanced Imaging, cardiac and therapy (MRI, CT, PET MysocardialPerfusion Imaging,

    1-800-424-4909 NA

    January 12, 2021 10

  • HEALTH PLAN INFORMATION MUGA Scan, Echocardiology, StressEchocardiology, Outpatient PT, OT, ST) (NIA)

    Cardiac Imaging (NIA)

    1-877-687-1169 (Relay Florida 1-800-955-8770)


    Envolve Vision

    Envolve Dental

    Interpreter Services NA

    To report suspected fraud, waste and abuse 1-866-685-8664 NA

    EDI Claims assistance 1-800-225-2573 ext. 6075525 e-mail:[emailprotected]

    January 12, 2021 11


  • SECURE PROVIDER PORTALAmbetter offers a robust Secure ProviderPortal with functionality that is critical to serving members andto ease administration for the Ambetter product for providers. ThePortal can be accessed at


    All users of the Secure Provider Portal must complete aregistration process.

    Once registered, providers may:

    o Check eligibility and view member roster

    o View the specific benefits for a member

    o View members remaining yearly deductible and amounts appliedto plan maximums

    o View status of all claims that have been received, regardlessof how submitted

    o Update provider demographic information (address, officehours, etc.)

    o For primary care providers, view and print patient lists. Thepatient list will indicate the member’s name, id number, date ofbirth, care gaps, disease management enrollment, and product inwhich they are enrolled

    o Submit authorizations and view the status of authorizationsthat have been submitted for members

    o View, submit, copy and correct claims

    o Submit batch claims via an 837 file

    o View and download explanations of payment (EOP)

    o View a member’s health record, including visits (physician,outpatient hospital, therapy, etc.), medications, andimmunizations

    o View gaps in care specific to a member, including preventivecare or services needed for chronic conditions

    o Send and receive secure messages with Ambetter staff

    o Access both patient and provider analytic tools

    Manage Account Access allows you to perform functions as anaccount manager such as adding portal accounts needed in youroffice.


    Providers agree that all health information, including thatrelated to patient conditions, medical utilization and pharmacyutilization available through the portal or any other means, willbe used exclusively for patient care and other related purposes aspermitted by the HIPAA Privacy Rule.

    January 12, 2021 12

  • CREDENTIALING AND RECREDENTIALINGThe credentialing andrecredentialing process exists to verify that participatingpractitioners and providers meet the criteria established byAmbetter, as well as applicable government regulations andstandards of accrediting agencies.

    If a practitioner/provider already participates with SunshineHealth in the Medicaid or a Medicare product, thepractitioner/provider will NOT be separately credentialed for theAmbetter product.

    Notice: In order to maintain a current practitioner/providerprofile, practitioners/providers are required to notify Ambetter ofany relevant changes to their credentialing information in a timelymanner but in no event later than 10 days from the date of thechange.

    Whether standardized credentialing form is utilized or apractitioner has registered their credentialing information on theCouncil for Affordable Quality Health (CAQH) website, the followinginformation must be on file:

    Signed attestation as to correctness and completeness, historyof license, clinical privileges, disciplinary actions, and felonyconvictions, lack of current illegal substance use and alcoholabuse, mental and physical competence, and ability to performessential functions with or without accommodation

    • Completed ownership and control disclosure form

    • Current malpractice insurance policy face sheet, whichincludes insured dates and the amounts of coverage

    • Current controlled substance registration certificate, ifapplicable

    • Current drug enforcement administration (DEA) registrationcertificate for each state in which the practitioner will seeAmbetter members

    • Completed and signed W-9 form (initial credentialing only)

    • Current educational commission for foreign medical graduates(ECFMG) certificate, if applicable

    • Current unrestricted medical license to practice or otherstate license;

    • Current specialty board certification certificate, ifapplicable;

    • Curriculum vitae listing, at minimum, a five year work historyif work history is not completed on the application with nounexplained gaps of employment over six months for initialapplicants

    • Signed and dated release of information form not older than120 days; and

    • Current hospital affiliation with admitting privileges.

    Ambetter will primary source verify the following informationsubmitted for credentialing and recredentialing:

    • License through appropriate licensing agency;

    • Board certification, or residency training, or professionaleducation, where applicable;

    • Malpractice claims and license agency actions through thenational practitioner data bank (NPDB);

    • Federal sanction activity, including Medicare/Medicaidservices (OIG-Office of Inspector General).

    January 12, 2021 13

  • For providers (hospitals and ancillary facilities), a completedFacility/Provider – Initial and Recredentialing Application and allsupporting documentation as identified in the application must bereceived with the signed, completed application.

    Once the clean application is received, the CredentialingCommittee will usually render a decision on acceptance followingits next regularly scheduled meeting in accordance to state andfederal regulations.

    Eligible Providers

    All eligible providers are required to complete thecredentialing process. All eligible providers must berecredentialed every 36 months.

    • Professional providers: MD, DO, DPM, DC, PsyD, PHD, AUD, BCBA,OD, DC, CNM, DPM, LCSW, LCPC, LMFT, PA, APN, APRN ANP and CNP, CNS,RD, LAC and DN

    • Institutional providers: Hospitals and Ancillary

    Non Registered CAQH Providers

    Primary care providers cannot accept member assignments untilthey are fully credentialed.

    Practitioners/Providers may self-register with CAQH ProView at The CAQH will email the provider awelcome kit with registration instructions. Practitioners/Providersreceive a personal CAQH Provider ID, allowing them to register onthe CAQH website at and obtain immediate access tothe ProView database via the Internet.

    Once obtaining authenticating key information,practitioners/providers will have the opportunity to create theirown unique user name as well as password to begin utilizing thesystem at any time.

    Credentialing Committee

    The Credentialing Committee, including the Medical Director ortheir physician designee, has the responsibility to establish andadopt necessary criteria for participation, termination, anddirection of the credentialing procedures. Committee meetings aretypically held at least monthly and more often as deemed necessary.Failure of an applicant to adequately respond to a request formissing or expired information may result in termination of theapplication process prior to committee decision.


    Ambetter conducts practitioner/provider recredentialing at leastevery 36 months from the date of the initial credentialing decisionor most recent recredentialing decision. The purpose of thisprocess is to identify any changes in the practitioner’s/provider’slicensure, sanctions, certification, competence, or health statuswhich may affect the practitioner’s/provider’s ability to performservices under the contract. This process includes allpractitioners, facilities, and ancillary providers previouslycredentialed and currently participating in the network.

    January 12, 2021 14


  • In between credentialing cycles, Ambetter conducts providerperformance monitoring activities on all networkpractitioners/providers. Ambetter reviews monthly reports releasedby both Federal and State entities to identify any networkpractitioners/providers who have been newly sanctioned or excludedfrom participation in Medicare or Medicaid. Ambetter also reviewsmember complaints/grievances against providers on an ongoingbasis.

    A provider’s agreement may be terminated if at any time it isdetermined by the Ambetter Credentialing Committee thatcredentialing requirements or standards are no longer beingmet.

    Practitioner Right to Review and Correct Information

    All practitioners participating within the network have theright to review information obtained by Ambetter to evaluate theircredentialing and/or recredentialing application. This includesinformation obtained from any outside primary source such as theNational Practitioner Data Bank, CAQH, malpractice insurancecarriers, and state licensing agencies. This does not allow aprovider to review references, personal recommendations, or otherinformation that is peer review protected.

    Practitioners have the right to correct any erroneousinformation submitted by another party (other than references,personal recommendations, or other information that is peer reviewprotected) in the event the provider believes any of theinformation used in the credentialing or recredentialing process tobe incorrect or should any information gathered as part of theprimary source verification process differ from that submitted bythe practitioner. Ambetter will inform providers in cases whereinformation obtained from primary sources varies from informationprovided by the practitioner. To request release of suchinformation, a written request must be submitted to your ProviderRelations Representative. Upon receipt of this information, thepractitioner will have 30 days from the initial notification toprovide a written explanation detailing the error or the differencein information to the Credentialing Committee.

    The Ambetter Credentialing Committee will then include thisinformation as part of the credentialing or recredentialingprocess.

    Practitioner Right to Be Informed of Application Status

    All practitioners who have submitted an application to join havethe right to be informed of the status of their application uponrequest. To obtain application status, the practitioner shouldcontact their Provider Relations Representative.

    Practitioner Right to Appeal or Reconsideration of AdverseCredentialing Decisions

    Applicants who are existing providers and who are declinedcontinued participation due to adverse credentialing determinations(for reasons such as appropriateness of care or liability claimsissues) have the right to request an appeal of the decision.Requests for an appeal must be made in writing within 30 days ofthe date of the notice.

    All written requests should include additional supportingdocumentation in favor of the applicant’s appeal or reconsiderationfor participation in the network. Reconsiderations will be reviewedby the Credentialing Committee at the next regularly scheduledmeeting and in accordance with state and federal regulations.

    January 12, 2021 15

  • Written requests to appeal or for reconsideration of adversecredentialing decisions should be sent to the attention of theMedical Director listed on the denial letter.

    January 12, 2021 16


    Provider Types That May Serve As PCPs

    Providers who may serve as primary care providers (PCP) includeFamily Medicine, Family Medicine-Adolescent Medicine, FamilyMedicine-Geriatric Medicine, Family Medicine-Adult Medicine,General Practice, Pediatrics, Pediatrics-Adolescent Medicine,Internal Medicine, Internal Medicine-Adolescent Medicine, InternalMedicine-Geriatric Medicine, Internist, Obstetrics and Gynecology,Gynecology, Physician Assistants, Advanced Practice RegisteredNurse, and Nurse Practitioners that practice under the supervisionof the above specialties.

    The PCP may practice in a solo or group setting or at aFederally Qualified Health Center (FQHC), Rural Health Center(RHC), Department of Health Clinic, or similar outpatient clinic.With prior written approval, Ambetter may allow a specialistprovider to serve as a PCP for members with special health careneeds, multiple disabilities, or with acute or chronic conditionsas long as the specialist is willing to perform theresponsibilities of a PCP as outlined in this Manual.

    Member Panel Capacity All PCPs have the right to state thenumber of members they are willing to accept into their panel.Ambetter does not and is not permitted to guarantee that anyprovider will receive a certain number of members.

    The PCP to member ratio shall not exceed the followinglimits:

    Practitioner Type

    Ratio General/Family Practitioners One per 2,500 members

    Pediatricians One per 2,500 members

    Internists One per 2,500 members

    If a PCP has reached the capacity limit for their practice andwants to make a change to their open panel status, the PCP mustnotify Ambetter 30 days in advance of their inability to acceptadditional members. Notification can be in writing or by callingthe Provider Services Department 1-877-687-1169 (Relay Florida1-800-955-8770). A PCP must not refuse new members for addition totheir panel unless the PCP has reached their specified capacitylimit.

    In no event will any established patient who becomes a member beconsidered a new patient. Providers must not intentionallysegregate members from fair treatment and covered services providedto other nonmembers.

    Member Selection or Assignment of PCP Ambetter members will bedirected to select a participating Primary Care Provider (PCP) atthe time of enrollment. In the event an Ambetter member does notmake a PCP choice, Ambetter will usually select a PCP based on:

    1. A previous relationship with a PCP. If a member has notdesignated a PCP within the first 30 days of being enrolled inAmbetter, Ambetter will review and assign the member to thatPCP.

    January 12, 2021 17

  • 2. Geographic proximity of PCP to member residence. Theauto-assignment logic is designed to select a PCP for whom themembers will not travel more than the required accessstandards.

    3. Appropriate PCP type. The algorithm will use age, gender, andother criteria to identify anappropriate match, such as childrenassigned to pediatricians.

    Pregnant members should be encouraged to select a pediatricianor other appropriate PCP for their newborn baby before thebeginning of the last trimester of pregnancy. In the event thepregnant member does not select a PCP, Ambetter will auto-assignone for their newborn.

    The member may change their PCP at any time with the changebecoming effective no later than the beginning of the monthfollowing the member’s request for change. Members are advised tocontact the Member Services Department at 1-877-687-1169 (RelayFlorida 1-800-955-8770) for further information.

    Withdrawing from Caring for a Member

    Providers may withdraw from caring for a member. Upon reasonablenotice and after stabilization of the member’s condition, theprovider must send a certified letter to Ambetter Member Servicesdetailing the intent to withdraw care. The letter must includeinformation on the transfer of medical records as well as emergencyand interim care.

    PCP Coordination of Care to Specialists

    When medically necessary care is needed beyond the scope of whatthe PCP can provide, PCPs are encouraged to initiate and coordinatethe care members receive from specialist providers. Paper referralsare not required.

    In accordance with federal and state law, providers areprohibited from making referrals for designated health services tohealthcare providers with which the provider, the member, or amember of the provider’s family or the member’s family has afinancial relationship.

    Specialist Provider Responsibilities Specialist providers mustcommunicate with the PCP regarding a member’s treatment plan andreferrals to other specialists. This allows the PCP to bettercoordinate the member’s care and ensures that the PCP is aware ofthe additional service request.

    To ensure continuity and coordination of care for the member,every specialist provider must:

    Maintain contact and open communication with the member’sreferring PCP

    • Obtain authorization from the Medical Management Department,if applicable, before providing services

    • Coordinate the member’s care with the referring PCP

    • Provide the referring PCP with consultation reports and otherappropriate patient records within five business days of receipt ofsuch reports or test results

    • Be available for or provide on-call coverage through anothersource 24 hours a day for management of member care

    • Maintain the confidentiality of patient medicalinformation

    January 12, 2021 18

  • • Actively participate in and cooperate with all qualityinitiatives and programs

    Appointment Availability and Wait Times

    Ambetter follows the accessibility and appointment wait timerequirements set forth by applicable regulatoryand accreditingagencies. Ambetter monitors participating provider compliance withthese standards atleast annually and will use the results ofappointment standards monitoring to ensure adequate appointmentavailability and access to care and to reduce inappropriateemergency room utilization. The table belowdepicts the appointmentavailability for members:

    Appointment Type Access Standard

    PCPs – Routine visits 30 days

    PCPs – Adult Sick Visit 48 hours

    PCPs – Pediatric Sick Visit 24 hours

    Behavioral Health – Non-life Threating Emergency Within 6 hours,or direct member to crisis center or ER

    Specialist Within 30 calendar days

    Urgent Care Providers 24 hours

    Behavioral Health Urgent Care 48 hours

    After Hours Care Phone Access within 6 Hours

    Emergency Providers 24 hours a day, 7 days a week

    Wait Time Standards for All Provider Types It is recommendedthat office wait times do not exceed 30 minutes before an Ambettermember is taken to the exam room.

    Travel Distance and Access Standards

    Ambetter offers a comprehensive network of PCPs, specialistphysicians, hospitals, behavioral health care providers, diagnosticand ancillary services providers to ensure every member has accessto covered services.

    The travel distance and access standards that Ambetter utilizesto monitor its network adequacy are in line with both state andfederal regulations. For the standard specific to your specialtyand county, please reach out to your Provider Servicesdepartment.

    January 12, 2021 19

  • Providers must offer and provide Ambetter members appointmentsand wait times comparable to that offered and provided to othercommercial members. Ambetter routinely monitors compliance withthis requirement and may initiate corrective action, includingsuspension or termination, if there is a failure to comply withthis requirement.

    Covering Providers

    PCPs and specialist providers must arrange for coverage withanother provider during scheduled or unscheduled time off. In theevent of unscheduled time off, the provider must notify theProvider Services department of coverage arrangements as soon aspossible. The provider who engaged the covering provider mustensure that the covering physician has agreed to be compensated inaccordance with the Ambetter fee schedule in such provider’sagreement.

    Provider Phone Call Protocol

    PCPs and specialist providers must:

    Answer the member’s telephone inquiries on a timely basis

    • Schedule appointments in accordance with appointment standardsand guidelines set forth in this manual

    • Schedule a series of appointments and follow-up appointmentsas appropriate for the member and in accordance with acceptedpractices for timely occurrence of follow-up appointments for allpatients

    • Identify and, when possible, reschedule cancelled and no-showappointments

    • Identify special member needs while scheduling an appointment(e.g., wheelchair and interpretive linguistic needs, non-compliantindividuals, or persons with cognitive impairments)

    • Adhere to the following response times for telephone call-backwait times:

    o After hours for non-emergent, symptomatic issues: within 30minutes

    o Same day for all other calls during normal office hours

    • Schedule continuous availability and accessibility ofprofessional, allied, and supportive personnel to provide coveredservices within normal office hours

    • Have protocols in place to provide coverage in the event of aprovider’s absence

    • Document after-hours calls in a written format in either inthe member’s medical record or an after-hours call log and thentransfer to the member’s medical record

    NOTE: If after-hours urgent or emergent care is needed, the PCP,specialist provider, or their designee should contact the urgentcare center or emergency department in order to notify the facilityof the patient’s impending arrival. Ambetter does not requireprior-authorization for emergent care.

    Ambetter will monitor appointment and after-hours availabilityon an on-going basis through its Quality Improvement Program(QIP).

    Provider Data Updates and Validation

    January 12, 2021 20

  • Ambetter believes that providing easy access to care for ourmembers is extremely important. When information (for instanceaddress, office hours, specialties, phone number, hospitalaffiliations, etc.) about your practice, your locations, or yourpractitioners changes, it is your responsibility to provide timelyupdates to Ambetter. Ambetter will ensure that our systems areupdated quickly to provide the most current information to ourmembers.

    Additionally, Ambetter, and our contracted vendors, performregular audits of our provider directories. This may be donethrough outreach to confirm your practice information. Access tocare is critical to ensuring the health and well-being of ourmembers, and in order to provide reliable access to care, it isimportant to respond to the outreach. Without a response, we areunable to accurately make your information available to patientsand you may be at risk of being removed from the Ambetter fromSunshine Health Provider Directory.

    We need your support and participation in these efforts. CMS mayalso be auditing provider directories throughout the year, and youmay be contacted by them as well. Please be sure to notify youroffice staff so that they may route these inquiriesappropriately.

    Hospital Responsibilities

    Ambetter has established a comprehensive network of hospitals toprovide services to members. Hospital services and hospital-basedproviders must be qualified to provide services under the program.All services must be provided in accordance with applicable stateand federal laws and regulations and adhere to the requirements setforth by accrediting agencies, if any, and Ambetter.

    Hospitals must:

    • Notify the PCP immediately or no later than the close of thenext business day after the member’s emergency room visit;

    • Obtain authorizations for all inpatient and selectedoutpatient services listed in the Pre-Auth Needed tool available, except for emergency stabilizationservices;

    • Notify the Medical Management department by either calling orsending an electronic file of the ER admission within one businessday; the information required includes the member’s name, memberID, presenting symptoms/diagnosis, date of service, and member’sphone number;

    • Notify the Medical Management department of all admissions viathe ER within one business day;

    • Notify the Medical Management department of all newborndeliveries within one day of the delivery; notification may occurby our Secure Provider Portal, fax, or by phone; and

    • Adhere to the standards set in the Timeframes for PriorAuthorization Requests and Notifications table in the MedicalManagement section of this manual.

    January 12, 2021 21



    There are many factors that determine which plan an Ambettermember will be enrolled in. The plans vary based on the individualliability limits or cost share expenses to the member. The phrase“Metal Tiers” is used to categorize these limits.

    Under the Affordable Care Act (ACA), the Metal Tiers includePlatinum, Gold, Silver, and Bronze. Essential Health Benefits(EHBs) are the same within every plan. This means that every healthplan will cover the minimum, comprehensive benefits as outlined inthe Affordable Care Act.

    The EHBs outlined in the Affordable Care Act are as follows:

    Preventive and wellness services and chronic diseasemanagement

    • Maternity and newborn care

    • Pediatric services including pediatric vision

    • Outpatient or ambulatory services

    • Laboratory services

    • Various therapies (such as physical therapy and devices)

    • Hospitalization

    • Emergency services

    • Mental health and substance use services, both inpatient andoutpatient

    • Prescription drugs

    Ambetter covers services described in the Schedule of Benefitsand Evidence of Coverage (EOC) document for each Ambetter plantype. If there are questions as to a covered service or requiredprior authorization, please contact Ambetter Provider Services at1-877-687-1169 (Relay Florida 1-800-955-8770).

    Detailed information about benefits and services can be found inthe current year EOC available at onthe “Our Health Plans” page.

    Each plan offered on the Health Insurance Marketplace will becategorized within one of these “Metal Tiers.” The tiers are basedon the amount of member liability. For instance, at a gold level, amember will pay higher premiums but will have lower out-of-pocketcosts, like copays. Below is a basic depiction of how the costlevels are determined within each plan.

    January 12, 2021 22

  • Our products are marketed under the following names:

    Metal Tier Marketing Name Gold Ambetter Secure Care SilverAmbetter Balanced Care Bronze Ambetter Essential Care

    Additional Benefit Information

    Ambetter has a variety of PPO, HMO, and EPO benefit plansofferings based on geographic location. Depending on the benefitplan and any subsidies that the member may receive, plans containcopays, coinsurance, and deductibles (cost shares). As statedelsewhere in this manual, cost shares may be collected at the timeof service. Review the “Verifying Member Benefits, Eligibility, andCost Shares” section of this manual to determine if the AmbetterMember has an HMO, EPO, or PPO plan.

    PPO To receive the highest level of benefits at the lowest costshare amounts, members who are enrolled with Ambetter PPO plans areincented to utilize in-network participating providers. If a memberreceives care from an out-of-network provider they will receivebenefit and they can be balanced bill for additional charges abovewhat has been reimbursed from the health plan. Members andproviders can identify participating providers by visiting ourwebsite at and clicking onFind-A-Provider.

    HMO Members who are enrolled in HMO plans with Ambetter mustutilize in-network participating providers. Members and providerscan identify other participating providers by visiting our websiteat and clicking on Find-A-Provider.When an out-of-network provider is utilized, except in the case ofemergency services, the member will be 100% responsible for allcharges.

    Integrated Deductible Products

    January 12, 2021 23


  • Some Ambetter products contain an integrated deductible, meaningthat the medical and prescription deductible are combined. In suchplans,

    • A member will reach the deductible first, then pay coinsuranceuntil they reach the maximum out-of-pocket for their particularplan

    • Copays will be collected before the deductible for servicesthat are not subject to the deductible • Other copays are subjectto the deductible, and the copay will be collected only afterthe

    deductible is met • Services counting towards the integrateddeductible include: medical costs, physician services,

    hospital services, essential health benefit covered servicesincluding pediatric vision and mental health services, and pharmacybenefits

    • Claims information including the accumulators will bedisplayed on the Secure Provider Portal

    Non- Integrated Deductible Products

    Some Ambetter products contain a non-integrated deductible,meaning that the medical and prescription deductible are notcombined. In such plans:

    A member will reach the medical deductible separately from theprescription deductible, then pay coinsurance until they reach themaximum out-of-pocket for their particular plan

    • Copays will be collected before the deductible for servicesthat are not subject to the deductible • Other copays are subjectto the deductible, and the copay will be collected only after thedeductible

    is met • Services that will not count towards the non-integratedprescription deductible include: medical

    costs, physician services, hospital services, essential healthbenefit covered services including pediatric vision and mentalhealth services, and any other medical benefits

    • Claims information including the accumulators will bedisplayed on the Secure Provider Portal

    Maximum Out-of-pocket Expenses

    All Ambetter benefit plans contain a maximum out-of-pocketexpense. Maximum out-of-pocket is the highest or total amount thatmust be paid by the member toward the cost of their health care(excluding premium payments). Maximum out-of-pocket costs can bedetermined on the Member’s Evidence of Coverage available on the “Our Health Plans” page. Beloware some rules regarding maximum out-of-pocket expenses:

    - A member will reach the deductible first, and will continue topay coinsurance/copay then pay coinsurance until they reach themaximum out-of-pocket for their Ambetter benefit plan.

    - Copays will be collected before and after the deductible ismet; or until the maximum out-of-pocket is met.

    - Only medical costs/claims are applied to the deductible. (Forthose benefit plans that contain routine adult vision and routinedental coverage, these expenses would not count towards thedeductible).

    - All out-of-pocket costs, including copays, deductibles, andcoinsurance apply to the maximum out-of-pocket. (As mentionedpreviously, this excludes premium payments).

    January 12, 2021 24

  • Free Visits

    There are certain benefit plans where three free visits areoffered. That is, these visits will not be subject to member costshares (copay, coinsurance or deductible).

    - These three free visits only apply to the evaluation andmanagement (E and M) codes provided by a Primary Care Provider orBehavioral Health Provider.

    - Preventive care visits are not included in the free visits. Asmentioned above, in accordance with the ACA, preventive care iscovered at 100% by Ambetter, separately from the free visits.

    - The Secure Provider Portal at hasfunctionality to “accumulate or count” free visits. It isimperative that providers always verify eligibility andbenefits.

    Covered Services

    Please visit the Ambetter website for information on services,the member’s coverage status and other information about obtainingservices. Please refer to our website and the “Medical Management& Prior Authorization” section of this manual for moreinformation about clinical determination and prior authorizationprocedures.

    Benefit Limits In general, most benefit limits for services andprocedures follow state and federal guidelines. Benefits limited toa certain number of visits per year are based on a calendar year(January through December). Please check to be sure the member hasnot already exhausted benefit limits before providing services bychecking our Secure Provider Portal or calling Ambetter Member andProvider Services.

    Preventive Services In accordance with the Affordable Care Act,all preventive services which meet U.S Preventive Services TaskForce (USPSTF) guidelines are covered at 100%. That is, there is nomember cost share (copay, coinsurance, or deductible) applied topreventive health services which meet USPSTF A and B ratings. Allpreventative diagnosis codes must be billed in the primary positionof the claim form.

    Diagnostic preventive procedures include but are not limitedto:

    Perinatal/Prenatal Care for pregnant members

    • Screening for infants up 24 months old

    • Screening for children and adolescents 2-18 years old

    • Screening for adults 19-64 years old

    Care for adults 65 years and older

    • Immunization schedules for children and adolescents

    • Immunization schedules for adults

    Diagnostic services, treatment, or services deemed as MedicallyNecessary to correct or improve defects, physical or mentalillnesses, and conditions discovered during a screening or testingmust be provided or

    January 12, 2021 25

  • arranged for either directly or through referrals. Any conditiondiscovered during the screening examination or screening testrequiring further diagnostic study or treatment provided will fallwithin the Member’s Covered Benefit Services. Member may haveadditional out-of-pocket cost share responsibility above standardcoverage for the initial preventive services. Members should bereferred to an appropriate source of care for any required servicesthat are not Covered Services.

    For a listing of services that are covered at 100% andassociated preventative benefits, please

    Notification of Pregnancy

    Providers should notify Marketplace/SBEs immediately of anymember who are expecting by completing the notification ofpregnancy form via the Ambetter Secure Provider Portal. We do notrequire that a physician or other healthcare provider obtain priorauthorization for the delivery of the newborn. However, aninpatient stay longer than 48 hours for a vagin*l delivery or 96hours for a cesarean delivery will require prior authorization.Please refer to the provider authorization to check if any authorizations arerequired for additional services.

    This notification of pregnancy allows Ambetter members to takeadvantage of the Start Smart for your Baby Program that provideseducation and care management techniques. The program offerssupport for pregnant women and their babies through the first yearof life by providing educational materials as well as incentivesfor going to prenatal, postpartum and well child visits.

    Adding a Newborn or an Adopted Child

    Coverage applicable for children will be provided for a newbornchild or adopted child of an Ambetter member from the moment ofbirth or moment of placement for adoptions if the eligible child isenrolled timely as specified in the member’s Evidence ofCoverage.

    Non-Covered Services

    Please refer to the member Evidence of Coverage for a listing ofnon-covered (excluded) services.

    Transplant Services

    Please refer to the member Evidence of Coverage for a listing ofcovered and non-covered (excluded) services related totransplants:

    Transplants are a covered benefit when a member is accepted as atransplant candidate. Prior authorization must be obtained throughthe “Center of Excellence”, before an evaluation for a transplant.We may require additional information such as testing and/ortreatment before determining medical necessity for thetransplantbenefit. Authorization must be obtained prior to performing anyrelated services to the transplant surgery. Transplant servicesmust meet medical criteria as set by Medical Management Policy.

    Claims submission shall be followed related to transplantservices is available to both the recipient and donor of a coveredtransplant as follows:

    If both the donor and recipient have coverage provided by thesame insurer each will have their benefits paid by their owncoverage program.

    January 12, 2021 26


  • • If you are the recipient of the transplant, and the donor forthe transplant has no coverage from any other source, the benefitsunder this contract will be provided for both you and the donor. Inthis case, payments made for the donor will be charged againstenrollees benefits.

    • If you are the donor for the transplant and no coverage isavailable to you from any other source, the benefits under thiscontract will be provided for you. However, no benefits will beprovided for the recipient.

    • If lapse in coverage due to non-payment of premium, noservices related to transplants will be paid as a coveredbenefit.

    • Ambetter transplant claims require submission to pricingvendor and the vendor will forward to Ambetter for payment. Pleaseensure you follow transplant vendor instructions provided byAmbetter to ensure timely claim processing.

    For additional questions or information on Prior Authorizationsplease review the Medical Management section of this manual forguidelines and for claim submission inquiries please outreach[emailprotected].

    Tribal Provider (AIAN) American Indian Alaska Native

    For Indian Health Services (I.H.S) and Tribal 638 facilities,most services are paid at the Office of Management and Budget (OMB)Rate, using the UB claim form and either a revenue code for dentalclinic (0512) or for physical health clinic (0519). For aBehavioral Health practitioner service revenue code 0919 is used.Some services are not part of the Office of Management Budget rateand are billed on the CMS 1500 form and paid at regular feeschedule rates.

    Ambetter American Indian and Alaska Natives members may use anIndian health care as a primary care provider or choose to use anetwork primary care provider to get health care services. To avoidpaying extra, member must obtain a referral from their Indianhealth care provider or from the network primary care provider forany specialty or other services not provided by your Indian healthcare provider.

    Ambetter claims billed by a network primary care provider orspecialist on behalf of an American Indian and Alaska Native memberare required to bill with modifier Q4 to indicate that theseservices are an extension of services not provided by an Indianhealth care provider, but billed by a network primary care provideror specialist.

    Ambetter requires that all Tribal 638 facilities billing on CMS1500 forms be billed with a place of service as recognized by CMS,,indicated below:

    • 05 Indian Health Service Free-Standing Facility. (A facilityor location, owned and operated by the Indian Health Service, whichprovides diagnostic, therapeutic (surgical and non-surgical), andrehabilitation services to American Indians and Alaska Natives whodo not require hospitalization. (Effective January 1, 2003).

    • 06 Indian Health Service Provider-Based Facility. (A facilityor location, owned and operated by the Indian Health Service, whichprovides diagnostic, therapeutic (surgical and non-surgical), andrehabilitation services rendered by, or under the supervision of,physicians to American Indians and Alaska Natives admitted asinpatients or outpatients. (Effective January 1, 2003).

    • 07 Tribal 638 Free-Standing Facility. (A facility or locationowned and operated by a federally recognized American Indian orAlaska Native tribe or tribal organization under a

    January 12, 2021 27


  • 638 agreement, which provides diagnostic, therapeutic (surgicaland non-surgical), and rehabilitation services to tribal memberswho do not require hospitalization. (Effective January 1,2003).

    • 08 Tribal 638 Provider-Based Facility. (A facility or locationowned and operated by a federally recognized American Indian orAlaska Native tribe or tribal organization under a 638 agreement,which provides diagnostic, therapeutic (surgical and non-surgical),and rehabilitation services to tribal members admitted asinpatients or outpatients. (Effective January 1, 2003).

    Ambetter requires that all other Non- Indian Health Services(I.H.S) or Tribal providers billing on UB and CMS 1500 forms bebilled in a place of services as recognized by CMS,

    January 12, 2021 28

  • MEMBER BENEFITS, MEMBER IDENTIFICATION CARD, ELIGIBILITY, ANDCOST SHARES It is imperative that providers verify benefits,eligibility, and cost shares each time an Ambetter member isscheduled to receive services.

    Member Benefits

    In general, most benefit limits for services and proceduresfollow state and federal guidelines. Benefits limited to a certainnumber of visits per year are based on a calendar year (Januarythrough December). In addition to verifying member benefits,eligibility and cost share, there may be further steps needed tohelp Ambetter members maximize their benefit coverage beforetreatment is rendered. offers aPre-Auth Check tool to determine if a pre-authorization is neededbefore services are rendered. This tool can be located at under the “For Providers” section ofthe site. This is in addition to other helpful tools andinformation Ambetter offers. Please check to be sure the member hasnot already exhausted benefit limits before providing services bychecking our Secure Provider Portal or calling Ambetter Member andProvider Services.

    Member Identification Card

    All members will receive an Ambetter member identificationcard.

    Below is a sample member identification card. The ID card mayvary due to the features of the health plan selected by themember.

    (The above is a reasonable facsimile of the MemberIdentification Card)

    NOTE: Presentation of a member ID card is not a guarantee ofeligibility. Providers must always verify eligibility on the sameday services are required.

    Preferred Method to Verify Benefits, Eligibility, and CostShares

    To verify member benefits, eligibility, and cost shareinformation, the preferred method is the Ambetter Secure ProviderPortal found at Using the Portal, anyregistered provider

    January 12, 2021 29


  • can quickly check member eligibility, benefits, and cost shareinformation. Eligibility and cost share information loaded ontothis website is obtained from and reflective of all changes madewithin the last 24 hours. The eligibility search can be performedusing the date of service, member name, and date of birth or themember ID number and date of birth.

    When searching for eligibility on the Secure Provider Portal,you will see one of the following statuses:

    Additional information regarding member premium grace periodrules may be found further down in this manual.

    Other Methods to Verify Benefits, Eligibility and CostShares

    24/7 Toll Fee Interactive Voice Response (IVR) Line at1-877-687-1169 (Relay Florida 1-800-955-8770)

    The automated system will prompt you to enter the member IDnumber and the month of service to check eligibility.

    January 12, 2021 30

  • Provider Services at 1-877-687-1169 (Relay Florida1-800-955-8770)

    If you cannot confirm a member’s eligibility using the secureportal or the 24/7 IVR line, call Provider Services. Follow themenu prompts to speak to a Provider Services Representative toverify eligibility before rendering services. Provider Serviceswill require the member name or member ID number and date of birthto verify eligibility.

    Importance of Verifying Benefits, Eligibility, and CostShares

    Benefit Design As mentioned previously in the Benefits sectionof this Manual, there are variations on the product benefits anddesign. In order to accurately collect member cost shares(coinsurance, copays and deductibles), you must know the benefitdesign. A member cost-sharing level and copayment is based on themember’s health plan. You can collect the copayment amounts fromthe member at the time of service. The Secure Provider Portal foundat will provide the informationneeded.

    Premium Grace Period for Members Receiving Advanced Premium TaxCredits (APTCs) A provision of the Affordable Care Act requiresthat Ambetter allow members receiving Advance Premium Tax Credit’s(APTC) a three month grace period to pay premiums before coverageis terminated.

    Members for whom Ambetter is not receiving an (APTC) will have agrace period of 30 days.

    When providers are verifying eligibility through the SecureProvider Portal during the first month of grace period, theprovider will receive a message that the member is delinquent dueto nonpayment of premium; however, claims may be submitted and willbe paid during the first month of the grace period. During monthstwo and three of the grace period, the provider will receive amessage that the member is in a suspended status. If payment of allpremiums due is not received from the member at the end of thegrace period, the member policy will automatically terminate to thelast date through which premium was paid. The member shall be heldliable for the cost of Covered Services received during the graceperiod, as well as any unpaid premium. In no event shall the graceperiod extend beyond the date the member policy terminates. Morediscussion regarding the three month grace period for non-paymentof premium may be found in the “Billing the Member” section of thismanual.

    January 12, 2021 31

  • MEDICAL MANAGEMENT The components of the Ambetter MedicalManagement program are: Utilization Management, Care Management andConcurrent Review, Health Management and Behavioral Health. Thesecomponents will be discussed in detail below.

    Utilization Management

    The Ambetter Utilization Management initiatives are focused onoptimizing each member’s health status, sense of well-being,productivity, and access to appropriate health care while at thesame time actively managing cost trends. The Utilization ManagementProgram’s goals are to provide covered services that are medicallynecessary, appropriate to the member’s condition, rendered in theappropriate setting, and meet professionally recognized standardsof care. Ambetter does not reward providers, employees who performutilization reviews, or other individuals for issuing denials ofauthorization. Neither network inclusion nor hiring and firingpractices influence the likelihood or perceived likelihood for anindividual to deny or approve coverage. There are no financialincentives to deny care or encourage decisions that result inunderutilization.

    Prior authorization is the request to the Utilization ManagementDepartment for approval of certain services before the service isrendered. Authorization must be obtained prior to the delivery ofcertain elective and scheduled services. Failure to obtainauthorization will result in denial of coverage.

    Medically Necessary

    Medically Necessary means any medical service, supply, ortreatment authorized by a physician to diagnose and treat amember’s illness or injury which:

    Is consistent with the symptoms or diagnosis;

    • Is provided according to generally accepted medical practicestandards;

    • Is not custodial care;

    • Is not solely for the convenience of the physician or themember;

    • Is not experimental or investigational;

    • Is provided in the most cost effective care facility orsetting;

    • Does not exceed the scope, duration, or intensity of thatlevel of care that is needed to provide safe, adequate, andappropriate diagnosis or treatment; and

    • When specifically applied to a hospital confinement, it meansthat the diagnosis and treatment of the medical symptoms orconditions cannot be safely provided as an outpatient.

    Timeframes for Prior Authorization Requests andNotifications

    The following timeframes are required of the ordering providerfor prior authorization and notification:

    Service Type Timeframe

    January 12, 2021 32

  • Scheduled admissions Prior Authorization required five businessdays prior to the scheduled admission date

    Elective outpatient services Prior Authorization required fivebusiness days prior to the elective outpatient service date

    Emergent inpatient admissions Notification one business dayObservation – 48 hours or less Notification within one business dayfor non-

    participating providers Observation – greater than 48 hoursRequires inpatient prior authorization within one

    business day Maternity admissions Notification within onebusiness day Newborn admissions Notification within one businessday Neonatal Intensive Care Unit (NICU) admissions Notificationwithin one business day Outpatient Dialysis Notification within onebusiness day Organ transplant initial evaluation PriorAuthorization required at least 30 days prior to

    the initial evaluation for organ transplant services. Clinicaltrials services Prior Authorization required at least 30 days priorto

    receiving clinical trial services.

    Utilization Determination Timeframes

    Authorization decisions are made as expeditiously as possible.Below is a list of specific timeframes utilized by Ambetter. Insome cases it may be necessary for an extension to extend thetimeframe below. You will be notified if an extension is necessary.Please contact Ambetter if you would like a copy of the policy forUM timeframes.

    Type Timeframe Pre-Service/Urgent Within seventy-two (72) hours(3 calendar days) of

    receipt of request. Pre-Service/Non-Urgent Within fifteen (15)calendar days of receipt of

    request. Concurrent/Urgent Within twenty-four (24) hours (1calendar day) of

    receipt of request. Extension: A onetime extension may begranted if additional information is needed. This will be requestedwithin 24 hours of receipt of request. The plan may then treat therequest as an urgent pre-service and make the decision within 72hours.

    Retrospective Within (30) calendar days of receipt ofrequest

    Services Requiring Prior Authorization

    To verify if a service requires prior authorization, pleasevisit the Ambetter website at and usethe “Pre-Auth Needed?” tool under For Providers – ProviderResources, or call the Utilization Management Department withquestions. Failure to obtain the required

    January 12, 2021 33

  • prior authorization or pre-certification will result in a deniedclaim. Note: All out of network services require priorauthorization, excluding emergency room services.

    It is the responsibility of the facility in coordination withthe rendering practitioner to ensure that an authorization has beenobtained for all inpatient and selected outpatient services, exceptfor emergency stabilization services. All inpatient admissionsrequire prior authorization.

    Any anesthesiology, pathology, radiology, or hospitalistservices related to a procedure or hospital stay requiring a priorauthorization will be considered downstream and will not require aseparate prior authorization.

    Services related to an authorization denial will result indenial of all associated claims.

    Procedure for Requesting Prior Authorizations

    Medical and Behavioral Health Secure Portal The preferred methodfor submitting authorizations is through the Secure Provider Portalat The provider must be a registereduser on the Secure Provider Portal. If a provider is alreadyregistered for the Secure Provider Portal for one of our otherproducts, that registration will grant the provider access toAmbetter. If the provider is not already a registered user on theSecure Provider Portal and needs assistance or training onsubmitting prior authorizations, the provider should contact theirdedicated Provider Partnership Manager. Other methods of submittingthe prior authorization requests are as follows:


    • Call the Medical Management Department at 1-877-687-1169(Relay Florida 1-800-955-8770). Our 24/7 Nurse Advice line canassist with urgent prior authorizations after normal businesshours.


    • Fax prior authorization requests utilizing the PriorAuthorization fax forms posted on the Ambetter website Please note: faxes will not bemonitored after hours and will be responded to on the next businessday. Please contact our 24/7 Nurse Advice Line at 1-877-687-1169(Relay Florida 1-800-955-8770) for after hour urgent admissions,inpatient notifications, or requests.

    The requesting or rendering provider must provide the followinginformation to request prior authorization (regardless of themethod utilized):

    • Member’s name, date of birth and ID number;

    • Provider’s Tax ID, NPI number, taxonomy code, name, andtelephone number;

    • Facility name if the request is for an inpatient admission oroutpatient facility services;

    • Provider location if the request is for an ambulatory oroffice procedure;

    January 12, 2021 34


  • • The procedure code(s); Note: If the procedure codes submittedat the time of authorization differ from the services actuallyperformed, it is required within 72 hours or prior to the time theclaim is submitted that you phone Medical Management at1-877-687-1169 (Relay Florida 1-800-955-8770) to update theauthorization; otherwise, this may result in claim denials;

    • Relevant clinical information (e.g. Past/proposed treatmentplan, surgical procedure, and diagnostic procedures to support theappropriateness and level of service proposed);

    • Admission date or proposed surgery date if the request is fora surgical procedure;

    • Discharge plans;

    • For obstetrical admissions, the date and method of delivery,targeted admission date, and information related to the newborn orneonate.

    Advanced Imaging As part of a continued commitment to furtherimprove advanced imaging and radiology services, Ambetter is usingNational Imaging Associates (NIA) to provide prior authorizationservices and utilization management for advanced imaging andradiology services. NIA focuses on radiation awareness designed toassist providers in managing imaging services in the safest andmost effective way possible.

    Prior authorization is required for the following outpatientradiology procedures:

    • CT /CTA/CCTA,

    • MRI/MRA, and

    • PET.

    Key Provisions:

    • Emergency room, observation, and inpatient imaging proceduresdo not require authorization;

    • It is the responsibility of the ordering physician to obtainauthorization; and

    • Providers rendering the above services should verify that thenecessary authorization has been obtained; failure to do so mayresult in denial of all or a portion of the claim.

    Cardiac Imaging Ambetter utilizes NIA to assist with themanagement of cardiac imaging benefits, including cardiac imaging,assessment, and interventional procedures.

    Habilitation and Rehabilitation Services As part of a continuedcommitment to further improve habilitation and rehabilitationservices, Ambetter is using National Imaging Associates (NIA) toprovide prior authorization services and utilization management foroutpatient physical, occupational and speech therapy services. NIAfocuses on assisting providers in managing habilitation, andrehabilitation services in the most effective way possible.

    How the Program Works Outpatient physical, occupational andspeech therapy requests are reviewed by NIA’s peer consultants todetermine whether the services meet policy criteria for medicallynecessary and appropriate care. The medical necessitydeterminations are based on a review of objective, contemporaneous,and clearly documented clinical records that may be requested tohelp

    January 12, 2021 35

  • support the appropriateness of care. Clinical review helpsdetermine whether such services are both medically necessary andeligible for coverage. Although prior authorization for the therapyevaluation alone is not required, additional services provided atthe time of the evaluation and for any ongoing care is requiredthrough NIA. There is no need to send patient records in advance.NIA will contact the provider via phone and fax if additionalclinical information is needed to complete the request. If theclinical documentation fails to establish that care is medicallynecessary, is not received, or is not received in an appropriateamount of time, it may result in non-certification of theauthorization request. Under terms of the agreement betweenAmbetter and NIA, Ambetter oversees the NIA Therapy Managementprogram and continues to be responsible for claims adjudication. IfNIA therapy peer reviewers determine that the care provided failsto meet our criteria for covered therapy services, you and thepatient will receive notice of the coverage decision.

    Prior authorization is required for the following therapyprocedures:

    - Physical Therapy, Occupational Therapy, Speech Therapy

    Key Provisions:

    - It is the responsibility of the ordering physician to obtainauthorization; and

    - Providers rendering the above services should verify that thenecessary authorization has been obtained; failure to do so mayresult in denial of all or a portion of the claim.

    Physical Medicine Program To help ensure that physical medicineservices (physical, occupational and speech therapy) provided toour members are consistent with nationally recognized clinicalguidelines, Ambetter has partnered with National ImagingAssociates, Inc. (NIA) to implement a prior authorization programfor physical medicine services. Effective January 1, 2021, NIAprovides utilization management services for outpatient physical,occupational and speech therapy services on behalf of Ambettermembers.

    How the Program Works Outpatient physical, occupational andspeech therapy requests are reviewed by NIA’s peer consultants todetermine whether the services meet policy criteria for medicallynecessary and appropriate care. The medical necessitydeterminations are based on a review of objective, contemporaneous,and clearly documented clinical records that may be requested tohelp support the appropriateness of care. Clinical review helpsdetermine whether such services are both medically necessary andeligible for coverage. Although prior authorization for the therapyevaluation alone is not required, additional services provided atthe time of the evaluation and for any ongoing care is requiredthrough NIA. There is no need to send patient records in advance.NIA will contact the provider via phone and fax if additionalclinical information is needed

Provider and Billing Manual · • Notify the Medical Management department of all newborn deliveries within one day of the delivery; notification may occur by our Secure Provider - [PDF Document] (2024)


Where do I mail my Ambetter of Tennessee claims? ›

Mail paper claims to: P.O. Box 5010 | Farmington, MO 63640-5010.

What is the payer ID for Ambetter of Tennessee? ›

Submitting Claims

For electronic submission, the Ambetter of Tennessee payor ID number is 68069.

What is the timely filing limit for Ambetter 2024? ›

The Ambetter timely filing requirement is 180 calendar days from the date of service (except for Michigan, which is 365 days); this includes resubmitting corrected claims that were not able to be processed. No reimbursem*nt will be made for claims received beyond this date.

What is the timely filing for Ambetter of Tennessee? ›

Timely Filing guidelines: 90 days from date of service.

What does Ambetter of Tennessee cover? ›

Every Ambetter insurance plan offers all of your Essential Health Benefits: Emergency services, outpatient or ambulatory services, preventive and wellness services, maternity and newborn care, pediatric services, mental health and substance abuse services, laboratory services, prescription drugs, therapy services (such ...

Does Ambetter of Tennessee have an app? ›

Download the app.

Smartphone apps are available through the Google Play Store (Android) and the App Store (iOS). Web apps are also available for computers.

What does payer ID mean for insurance? ›

The Payer ID or EDI is a unique ID assigned to each insurance company. It allows provider and payer systems to talk to one another to verify eligibility, benefits and submit claims. The payer ID is generally five (5) characters but it may be longer. It may also be alpha, numeric or a combination.

What is the phone number for Ambetter of Tennessee billing? ›

You can also reach us from 8am-8pm CDT at 1-833-709-4735 (Relay 711).

What is the payer ID for health Management Associates? ›

We accept electronic claims through Availity using payer ID HMA01. You can also submit claims via mail to our claims address P.O. Box 85008 Bellevue WA 98015 or fax at 1-866-458-5488. What is HMA's holiday schedule?

How long has Ambetter insurance been around? ›

About Ambetter health insurance

Established in 1984, Ambetter believes that healthcare is best delivered locally, with a focus on offering affordable and accessible health insurance solutions. Ambetter offers health plans with 3 coverage levels and aims to reduce out-of-pocket healthcare costs.

What is the grace period for Ambetter NC? ›

After you pay your first bill, you have a grace period of 30 calendar days. During this time, we will continue to cover your care, but we may hold your claims. We will notify the member of the non-payment of premiums, as well as providers of the possibility of denied claims.

What is the timely filing limit for Ambetter NC appeal? ›

You have up to 180 days after date of the denial to request a Formal Appeal. Ambetter from Health Net's Appeals and Grievances Department will oversee the processing of your appeal.

What is timely filing for TennCare? ›

Q: What is the timely filing deadline? A: TennCare requires claims to be filed within one (1) year from the date of service, or six (6) months from Medicare's pay date.

How many laps is the Ambetter? ›

How many laps is the Ambetter Health 400? Atlanta Motor Speedway is 1.5 miles (2.41 km) long and a 400-mile race that requires 260 laps to complete.

What is the timely filing limit for Aetna Tennessee? ›

Within 180 calendar days of the initial claim decision.

What is the phone number for Ambetter of Tennessee credentialing? ›

For Providers

Our customer call center at 1-833-709-4735 can verify eligibility and benefits for any out-of-state members for you. The call center staff can be reached between 8 AM and 5 PM.

Where do I mail claims to Memorial Hermann health Plan? ›

Verification does not apply to self-funded plans. Availity or THIN Payor ID: MHHNP Emdeon or WebMD Payor ID: TH092 • Mail paper claims to: MHHP Claims Department P.O. Box 660303 Dallas, TX 75266-0303 • Paper claims must be submitted on the Standard CMS-1500 (02/12) or UB-04 claim form.

What is the phone number for the Ambetter of Tennessee Rewards program? ›

Contact us at 1-833-709-4735 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

How do I contact Ambetter, SC? ›

Get complete healthcare coverage in South Carolina with Ambetter from Absolute Total Care. Check out the map below to see where we offer our Marketplace plans. Find coverage in your area. Call us today at 1-833-270-5443 (Relay 711).


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