Q3 2026 Provider Newsletter

Date: 08/25/26

Mental Health Awareness Month

September begins Suicide Prevention Awareness Month, which is a crucial time dedicated to raising awareness about mental health struggles and suicide prevention. The nationwide observance strives to raise awareness about the stigmatized topic, identify ways to prevent suicide, and to remember all of the lives that have been lost and affected by suicide. As part of the National campaign: National Suicide Prevention Week is observed September 13, 2026 - September 19, 2026 with World Suicide Prevention Day being recognized on September 10, 2026.  

Our team wants to offer support by sharing several resources below.

• 988 Suicide & Crisis Lifeline: a 3-digit number for connecting with crisis counselors 24/7.
• AL Department of Mental Health and Substance Abuse Services: Alabama Department of Mental Health – connecting mind and wellness

• AL Suicide Prevention Network: Alabama Suicide Prevention & Resources Coalition

If you or someone you know is in immediate danger or experiencing a mental health emergency, call 988 or call 911.

Breast Cancer Awareness Month

With Breast Cancer Awareness Month just around the corner beginning in October, we wanted to take a moment to acknowledge all who have been affected by the disease and its effects. Breast Cancer Awareness Month is a time annually devoted to a number of campaigns and programs designed to support those who have been diagnosed with breast cancer, educate people about breast cancer risk factors, encourage regular breast cancer screenings, and raise money for breast cancer research.

Regular mammogram screenings are an important part of preventative care. If applicable, please reach out to your primary care provider for guidance on scheduling this recommended preventative service.

Important Prior Authorization Updates

Effective October 1, 2026

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Ambetter of Alabama wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care. 

Code change details are noted in the table below. The changes may include:

• Removing PA requirements based on criticality of review and clinical need. 
• Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests. 

For questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.

Risk Adjustment

Risk Adjustment Data Validation (RADV)

Ambetter of Alabama has officially launched our annual RADV Audit Chart Chase Project, and we need your assistance in responding to a Health & Human Services (HHS) mandated audit. HHS initiates audits of health plans subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Alabama is included in the audit and we, along with our contracted providers, must fully comply. Please prioritize the medical record requests coming from the vendor Optum.

Continuity of Care Plus

Ambetter of Alabama remains committed to supporting providers in delivering high‑quality care to our members. As part of that effort, we are currently active for our 2026 Continuity of Care Plus (CoC+) Program. This initiative integrates Appointment Agendas, HEDIS measures, and pharmacy metrics into a single, comprehensive view. The CoC+ Program is designed to support outreach for annual wellness visits, chronic condition management, and closing care gaps. It also provides visibility into members with high utilization patterns or multiple ER visits, helping identify candidates for case management. Overall, this program empowers primary care providers to deliver more proactive, preventive, and coordinated care—ultimately supporting improved clinical quality. Eligible providers may earn up to $450 per patient, depending on the line of business, by meeting program‑specific requirements. For more details regarding the CoC+ Program and the Provider Incentive Payout Bonus, please visit the provider portal or contact your health plan representative.

Did you know? We offer Continuity of Care Plus (CoC+) and Centene Clinical Action Portal (CCA) webinar series. Join us for a focused overview of the CoC+ program and how it supports coordinated, patient-centered care.

What we will cover:

• CoC+ program overview and key components
• Quality, high utilization, risk and actionable insights
• How to use CCA/CoC+ (Agenda submissions)
• Ways to support documentation and continuity of care

Who Should Attend:

This session is intended for provider office staff involved in patient care coordination and performance improvement, including:

• Providers/Clinicians
• Billing/Coding Staff
• Office Managers/administrators
• Any team members using CCA/CoC+

These sessions are designed to help your team get the most out of the CoC+ program. To register, please contact your health plan representative. We appreciate your partnership and look forward to helping you get the most out of these programs.

Clinical Documentation Improvement (CDI) 2026 Webinar Series 

Did you know? We offer Risk Adjustment, Coding and Documentation Education. Join us for engaging sessions that enhance your documentation and coding expertise. Click here to Register!

• Learn practical risk adjustment strategies through real-world case studies
• Strengthen documentation to capture the full scope of each patient’s condition
• Master the ICD-10-CM coding guidelines to ensure precise, compliant coding
• Build confidence to document and code with accuracy that supports better outcomes

Live sessions built for providers, non-physician practitioners, coders, billers, and support staff, because great documentation and coding starts with a great team! Advanced registration is required. Utilize the corresponding registration link provided for each topic to register (links are unique to each webinar). If you have questions or need assistance with registration, email us at: CDIWebinars@centene.com

Evolent Musculoskeletal Program Updates

Effective December 5, 2026

Ambetter of Alabama in collaboration with Evolent is implementing updates to how Musculoskeletal services are reviewed and administered to enhance the member and provider experience. These changes reflect a shared commitment to improving quality of care, efficiency, reducing administrative burden, and supporting timely, clinically appropriate care decisions.

What’s Changing?

Site of care selection for shoulder, hip, knee and spine surgeries

Advances in surgical care have enabled many procedures that once required inpatient stays to be safely performed in outpatient settings.

Beginning 12/5/2026, Evolent will guide ordering providers, during intake of an authorization request for Ambetter of Alabama members, to select a preferred site of care. If a hospital-based setting is selected for a procedure that can be performed in an outpatient setting, providers will be required to either choose from a list of allowable exceptions or provide supporting clinical justification.

Clinical reviewers will evaluate both medical necessity and site of care criteria prior to rendering a determination. Once the authorization request is complete, the final authorization will reflect determinations for both the procedure and the site of care.

For questions or additional information, please contact your Provider Engagement representative.

Quality Improvement

Ambetter Health Partners with 86Borders to Support Members in Alabama.

Ambetter Health is partnering with 86Borders, a local member engagement and care coordination company, to provide personalized outreach and support to members in Alabama.

86Borders is engaging members who may benefit from additional support, including high-risk members, individuals with frequent emergency room visits, members with multiple gaps in care, some pregnant individuals, and members who have historically been difficult to reach through traditional outreach methods.

Through one-on-one communication, 86Borders Care Coordinators work to understand each member’s needs, identify and resolve social drivers of health (SDOH) barriers, and reconnect members with their primary care providers. Care Coordinators may also help members access transportation, food, housing, health plan resources, preventive screenings, prenatal care, chronic condition management, and other services that support their health and well-being.

The goal of this partnership is to improve access to care, strengthen members’ relationships with their primary care providers, close gaps in care, and reduce avoidable emergency room utilization. This support is provided at no cost to Ambetter Health members.

Providers may hear from Care Coordinators who are assisting members with scheduling appointments, addressing barriers, and navigating available healthcare and community resources.

For any questions, please contact Dawn Massey.

Provider Appointment Standards for Scheduling

To ensure our members receive services for medical and behavioral health appointments in a timely manner, below are the Appointment Availability Standards we ask our providers to implement accordingly. These can also be found in the provider manuals.

Community Events

Ambetter of Alabama is committed to supporting our community. Below are recent events that we supported within Alabama recently. Do you have an upcoming event or ideas for us to partner with you to help support our members? If so, you we would love to hear your thoughts and ideas. Please contact Trillo Shipman, Director of Community Relations.

Ambetter of Alabama Provider Expo Roadshow - Mobile

Ambetter of Alabama Provider Expo Roadshow - Mobile

Ambetter of Alabama Provider Expo Roadshow - Mobile

Franklin Primary Health Center - Annual Community Health Back-to-School Bash

Clinic Days

If you are interested in putting on a clinic day, please reach out to our Alabama Provider Relations team.

Provider Manual

Ambetter of Alabama is committed to disseminating comprehensive and timely information to its providers through the 2026 Provider and Billing Manual regarding Ambetter’s operations, policies, and procedures. Updates to this manual will be posted on our website at AmbetterHealth.com/en/al.

Verifying Member Eligibility & Claims Risk

Thank you for the care you provide to our Ambetter of Alabama members. As a valued partner, we’re committed to supporting smooth, efficient business operations. We’d like to share a few helpful reminders and tips to support seamless interactions and transactions.

Before rendering services, please remember to verify three key items for every Ambetter of Alabama member:

1. Member Eligibility Status
2. Premium Paid Through Date
3. Claims Paid Through Date

These items can be verified through Availity Essentials and other Ambetter of Alabama secure portals.

Why This Matters

Marketplace members are responsible for paying monthly premiums. Members who miss payments may enter a Grace Period, which can affect whether claims are paid, pended, or denied—especially depending on whether the member receives an Advanced Premium Tax Credit (APTC).

Claims submitted for dates of service during a Grace Period may:

• Be considered for payment
• Be placed in a pending (pend) status
• Be denied if the member does not return to good standing and coverage is terminated

Understanding Eligibility Statuses

When reviewing eligibility, you may see the following:

• Active – Member is in good standing; premiums paid
• Active – Pending Investigation (Availity only) – Member is behind on premiums
• Delinquent (non-Availity portals) – Member is behind on premiums; Claims Paid Through Date is in the future
• Suspended (non-Availity portals) – Member is behind on premiums; Claims Paid Through Date is in the past
• Inactive – Coverage terminated; member is no longer eligible

The Premium Paid Through Date shows the last date premiums were paid.
The Claims Paid Through Date shows the last date of service for which claims will be paid or considered for payment.

Claims for dates of service after the Claims Paid Through Date are at risk for pending or denial if the member does not pay outstanding premiums.

Seeing Members Not in Good Standing

If a member is not in good standing with premium payments:

• Providers may collect full billed charges at the time of service.
• If the member later pays outstanding premiums and coverage is reinstated, a claim may be submitted.
• If that claim is paid, the provider must reimburse the member in accordance with the Provider Agreement.

Members with Active – Pending Investigation, Delinquent, or Suspended statuses should be referred to their responsibilities outlined in the Ambetter of Alabama Member Handbook.

Need Help?

If you have questions about eligibility verification, Grace Period rules, claims submission, or using Availity Essentials and the Ambetter of Alabama portals, please contact your Provider Engagement representative.

Reminders

Thank you for being a valued partner in our provider network!

If you receive a survey from us, please provide honest feedback regarding your experience with us. Sharing your experience in this brief survey is how you can help us gain valuable insights to enhance and improve provider tools, resources, and operations to better support you.

We look forward to receiving your valuable feedback. Thank you!

• We offer Alabama Provider Town Halls monthly on every 2nd Tuesday at 12 PM CT/1 PM ET.
• Please utilize all features & functions found in our Ambetter of Alabama website.
• Remember to contact your Provider Engagement Administrator with any demographic updates.
• Providers can create an account or login to our portal HERE.
• Do you have ideas for the newsletter? Please contact Amber Howell.