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Provider Manuals and Forms | Ambetter from Home State Health
Provider Resources
Ambetter Health provides the tools and support you need to deliver the best quality of care.
Reference Materials
- 2026 Provider and Billing Manual (PDF)
- 2025 Provider and Billing Manual (PDF)
- Quick Reference Guide (PDF)
- Pharmacy Guide (PDF)
- Claims, Disputes & Recovery/CCU Guide (PDF)
- ICD-10 Information
- Payspan (PDF)
- Secure Portal (PDF)
- Ambetter Taxonomy (PDF)
- Hemophilia Network Posting
- TurningPoint Healthcare Solutions
- No Surprises Act Open Negotiation Form (PDF)
- Non-Formulary And Step Therapy Exception Request Form (PDF)
- Spine Surgery - Evolent Utilization Matrix (PDF)
- Joint Surgery - Evolent Utilization Matrix (PDF)
- NIA Utilization Matrix (PDF)
- Clean Claim Vendor FAQs (PDF)
- Availity Editing Services (PDF)
- Transitions to Availity Essentials (PDF)
- Provider Appointment Standards for Scheduling (PDF)
- Interpreter Request Form (PDF)
- Oncology Quality Management Program Radiation Oncology FAQ (PDF)
- Care Management (PDF)
Medical Management/Behavioral Health
- Pre-Auth Needed?
- Prior Authorization Guide (PDF)
- Prior Authorization (PA) Supplemental Form (PDF)
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Outpatient Authorization Supplemental Form (PDF)
- Provider Fax Back Form (PDF)
- MO Marketplace Out of Network Form (PDF)
- Ambetter from Home State Health Oncology Pathway Solutions FAQs (PDF)
- National Imaging Associates, Inc. FAQs (PDF)
- Physical Medicine Prior Authorization QRG - NIA (PDF)
- Discharge Planner Checklist (PDF)
- Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)
Quality
- Quality Improvement (QI)
- Practice Guidelines (PDF)
- Controlling High Blood Pressure Coding Sheet (PDF)
- HEDIS 2021 QRG (PDF)
- Providing Quality Care
Opioid Toolkit
- Pharmacy Lock-in Program
- Summary Guidelines - Office of the Surgeon General - Centers for Disease Control (CDC) Guidelines: Turn the Tide Rx Prescribing Opioids for Pain (PDF)
- Pain Management and Opioid Online Training - Complimentary Pain Management & Opioid Course (CME Credit Available) (PDF)
Fluvention
Other
CMS Interoperability & Prior Authorization Final Rule: CY2025 Prior Authorization Requirements Reports and Metrics Summaries
In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS 0057 F), we are annually publishing our prior authorization requirements and performance metrics to promote transparency, accountability, and better support our members and providers.
Reports:
- Ambetter from Home State Health CMS Final Rule 0057-F Prior Authorization Requirements: 99723 (PDF)
- Ambetter from Home State Health Prior Authorization Metrics Summary: 99723 (PDF)
The data presented in these publications reflects prior authorization requests processed during the applicable measurement year in accordance with CMS reporting specifications. Metrics are calculated using CMS defined methodologies and may not be directly comparable to alternative reports or third party summaries.