Ambetter Health Prior Authorization Update

Date: 05/09/25

Prior Authorization No Longer Needed for this Ambetter Health Code

Ambetter Health requires prior authorization (PA) as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Florida Marketplace products offered by Ambetter Health.

Effective June 1, 2025, the following code will no longer require prior authorization to be submitted to Ambetter Health:

81257: HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring)

Ambetter Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a

process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.

For complete CPT/HCPCS code listing, please see Prior Authorization Tool on our website.

The preceding code(s) included in the document represent the national, standard code sets. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. Please refer to your contract with Ambetter Health to determine all contracted/covered codes for each membership group. Please refer to the Provider and Billing Manual for a list of approved modifier codes.

Questions?

Ambetter Health has a wealth of resources available to help answer your questions and address your concerns:

• Provider Services: Call 1-877-687-1169
• Provider Portal: Visit the Secure Provider Portal to check member eligibility, submit claims and more.
• Provider Engagement: Use the Find Your Account Manager tool to find the Provider Engagement Account Manager (PEAM) supporting your specialty and region.
• Provider News: Bookmark Provider News to keep up with the latest updates.
• Provider Newsflash: Subscribe to our e-newsletter to get regular updates.
• Provider Resources: Visit Ambetter Health Provider Resources to find provider manuals, forms and other resources