Verifying Eligibility for Out-of-State Ambetter Members

Date: 11/30/22

When treating members from other Ambetter plans across the country, Ambetter from Louisiana Healthcare Connections participating providers are reminded to verify the member’s network and plan before extending care. This information is located on the member’s ID card and can also be confirmed when verifying the member’s eligibility in the secure provider portal.

To secure prior authorization for services for an out-of-state Ambetter member, visit AmbetterHealth.com to locate the correct state-specific Ambetter website and access their Pre-Auth tool. If pre-auth is required, submit the request through the secure member portal. You can also submit a manual request via fax by using the form on the state-specific Ambetter website.  Note: Emergency services do not require prior authorization or pre-approval.

Please refer to the descriptions and sample ID cards for each plan type below.

Ambetter Gold, Silver and Bronze Plans

Out-of-state Ambetter members with Gold, Silver, and Bronze plans benefit from reciprocity and can receive care from Ambetter from Louisiana Healthcare Connections participating providers. Referrals from PCPs are not required to see a specialist, but some services may require prior authorization.

Ambetter Value Plans

Some Ambetter members from Superior Healthplan (Texas), Ambetter from Sunshine Health (Florida), and Ambetter from SilverSummit HealthPlan (Nevada) may have a plan that is limited to providers in their state’s Ambetter Value network only. These members can be identified by the word “Value” on their ID card and “Ambetter Value” on the secure provider portal.

Claims for out-of-state Ambetter Value Plan members will be denied if pre-approval for services is not received.

Ambetter Virtual Access Plans

Some states offer Ambetter Virtual Access plans, which offer a virtual primary care experience in addition to the Ambetter core network of health care providers. Depending on the state where the plan is offered, Ambetter Virtual Access plans may or may not require referral to see specialists. These members can be identified by the words “Virtual Access” on their ID card and “Ambetter Virtual Access” on the secure provider portal. Please verify eligibility and plan benefits on the provider portal before extending care.