News

Q2 2026 Provider Newsletter

Date: 05/18/26

Mental Health Awareness Month

May begins Mental Health Awareness Month, a time when we are reminded of the daily challenges our healthcare providers encounter. Our team wants to offer support to our providers and administrative staff through various resources below. We encourage you to take a moment to explore the following links and disseminate the valuable information within your teams. These include the 988 document and information from the CDC, NAMI, AHRQ, and ACOG about physician burnout. Sharing may help a teammate navigate the complexities of your roles while prioritizing mental health.

Update for Procedure Codes S9083 and S9088 - Effective 8/1/2026

Effective 8/1/2026, the following procedure codes will become reimbursable when billed with place of service 20 (urgent care facilities). Claims submitted with another place of service will be denied, as these codes are not reimbursable for those locations.

Code S9083: Global fee urgent care centers
- Represents a facility-level global urgent care service.
- Indicates the member is physically seen in an urgent care setting.
Code S9088: Urgent care add-on code
- Used only in addition to an E/M procedure code.
- Indicates urgent care optional costs.
- Used when services are provided in person in an urgent care setting.

If you have questions about the bulletin or other provider resources, please contact your Provider Relations Representative.

Risk Adjustment

Risk Adjustment Data Validation (RADV)

In June, Ambetter of Alabama will be launching our annual RADV Audit Chart Chase Project, and we need your assistance in responding to a Department of Health & Human Services (DHHS) mandated audit. The 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.

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, complaint 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.

86Borders-Human Connections

Ambetter of Alabama is partnering with 86Borders in a pilot project to support high-risk patients who are not consistently engaging in primary or preventative care. 86Borders is a member relationship and care coordination company that engages members through trusted, one-to-one outreach with coordinators who are based in Alabama…not AI. This pilot runs through December 2026. Learn more below about how they work and their goals.

How 86Borders Supports Providers

Improves Patient Engagement & Visit Completion

Outreach to patients who have not been seen recently or who frequently use the ER
Assistance scheduling PCP and follow-up visits
Appointment reminders and barrier resolution to reduce no-shows

Supports Chronic Condition Management

Encourages patients to attend visits where ongoing conditions can be assessed
Reinforces medication adherence and preventative care
Helps patients understand the importance of regular primary care

Reduces Avoidable ER Utilization

Educated patients on appropriate site of care (urgent care vs ER)
Helps address drivers of ER use such as transportation barriers, medication access issues, or lack of PCP connection

Addresses Social Barriers That Affect Your Panel

Identifies needs such as food insecurity, housing instability, or financial challenges
Connects patients to community resources
Supports behavioral health and specialty referrals

Helps Maintain Accurate Network Information

Provides feedback to the health plan when
- Panels are closed
- Office locations or hours change
- Access challenges are identified

By the end of the year, this pilot project focusing on high-risk patients hopes to: improve continuity of care and primary care utilization, support accurate evaluation of chronic conditions during visits, reduce avoidable emergency room visits, improve patient experience and engagement, and strengthen overall Quality performance.

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.

Payment Program Updates

Description of Changes:

Non-Exact Duplicate Facility Stay:
Recouping non-exact duplicate inpatient hospital claims that represent the same inpatient stay but were billed more than once. This initiative identifies inpatient claims for the same member, provider, and hospital with overlapping dates of service where an additional claim falls within the original inpatient stay but was billed under a different DRG or Type of Bill.

The concept supports payment accuracy by ensuring that only one appropriate inpatient DRG payment is made per admission in line with CMS inpatient billing requirements.

Changes to existing review criteria will go into place on or after 6/1/2026.

Claims system denial code remains ‘h2’ with a provider letter verbiage of: ‘The reason for recovery “The member was ineligible for coverage on the date of service. An overpayment of $XX will be recouped".’

Effective 7/1/2026, Ambetter of Alabama will begin applying national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels. Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to practitioners. The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.

Overview of Ambetter of Alabama E&M Program:

Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service.
Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process.

According to the Federal Registrar and American College of Emergency Physicians, the level of service for the emergency department (ED) Evaluation and Management (E/M) codes is based primarily on the resources utilized by the facility and staff of the ED. Facility resources include, but are not limited to, nursing time, clinical staff effort, supplies, equipment, and overhead directly related to the patient’s care, as distinct from the physician’s cognitive work. Professional E/M codes for providers are reported to capture the clinical complexity and intensity of the work performed by the provider; however, E/M codes for facilities are reported for the amount and intensity of resources utilized by the facility to provide the care of the patient.

Policy Number: CC.PP.80
Policy Name: Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services

EX Codes:
• AMISYS: EXLc

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 as we begin the new year. To help start the year off right, 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:

Member Eligibility Status
Premium Paid Through Date
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.