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Manuals & Forms for Providers | Ambetter of Tennessee
Provider Resources
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Reference Materials
- 2025 Provider Welcome Letter (PDF)
- 2026 Provider and Billing Manual (PDF)
- 2025 Provider and Billing Manual (PDF)
- 2026 Provider Orientation (PDF)
- Pharmacy Guide (PDF)
- Quick Reference Guide (PDF)
- Claims, Disputes & Recovery/CCU Guide (PDF)
- ICD-10 Information
- Payspan (PDF)
- Secure Portal (PDF)
- Health Literacy and Culture (PDF)
- Telehealth and Virtual Services Guide (PDF)
- Step Therapy Exception Request Form (PDF)
- Provider Awareness Handout (PDF)
- Provider Awareness Flyer (PDF)
- Provider Rep. Territory Contact List (PDF)
- 2025-2026 Appointment Standards for Scheduling (PDF)
- Interpreter Request Form (PDF)
- Care Management (PDF)
Quality Improvement
- Quick Reference Guide, HEDIS® MY 2025 (PDF)
- HEDIS® Adult Pocket Guide: 2025 Measurement Year (PDF)
- HEDIS® Pediatric Pocket Guide: 2025 Measurement Year (PDF)
- Quality Improvement (QI) Program
- Centene Vision Services Eye Exam for Patients with Diabetes (EED) Tip Sheet
- Marketplace Pay-for-Performance (P4P) Program (PDF)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS) (PDF)
- Provider CAHPS Tip Sheet (PDF)
- Supplemental Data System(SuDS) Submission Process (PDF)
- International Normalizing Ratio Monitoring for Individuals on Warfarin (INR) (PDF)
- Use of Imaging Studies for Low Back Pain (LBP) (PDF)
- Cervical Cancer Screening (CCS) (PDF)
- Chlamydia Screening in Women (CHL) (PDF)
- Controlling Blood Pressure (CBP) (PDF)
- Childhood Immunization Status (CIS) (PDF)
- Appropriate Testing for Pharyngitis (CWP) (PDF)
- Eye Exam for Patients with Diabetes (EED) (PDF)
- Immunizations for Adolescents (IMA) (PDF)
- Proportion of Days Covered: Diabetes All Class (PDC-DR) (PDF)
- Timeliness of Prenatal & Postpartum Care (PPC) (PDF)
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) (PDF)
- Child and Adolescent Well-Care Visits (WCV) (PDF)
- Respiratory Syncytial Virus (RSV) (PDF)
Risk Adjustment
- Continuity of Care Program (PDF)
- Continuity of Care Program Appointment Agenda (PDF)
- 2024 Tiered Incentive Payments (PDF)
Medical Management
- Prior Authorization Guide
- Prior Authorization Guide (PDF)
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form Continuation (PDF)
- Prior Authorization Request Form for Non-Specialty Drugs (PDF)
- Tennessee Prior Authorization Fairness Act (HB 0885)
Behavioral Health
- Telehealth (TeleBH) (PDF)
- Suicide Awareness and Education
- Optimizing the AMM, FUH, and IET HEDIS Measures Training
- Behavioral Telehealth (PDF)
- Coordination of Care Checklist (PDF)
- PCP/BH Provider Communication Form (PDF)
- Improving Patient Engagement in Behavioral Healthcare (PDF)
- Follow-Up After Hospitalization for Mental Illness (PDF)
- Discharge Planner Checklist (PDF)
- Antipsychotic and Antidepressant Medication Adherence (PDF)
- Initiation and Engagement of Substance Use Disorder Treatment (IET) (PDF)
- CDC’s Efforts to Prevent Overdoses and Substance Use-Related Harms
- 2024 Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)
- 2025 Quality Rating System (QRS) Behavioral Health Measure Toolkit (PDF)
Claims and Claims Payment
- Provider Request for Reconsideration and Claim Dispute Form (PDF)
- No Surprises Act Open Negotiation Form (PDF)
- Consent for Sterilization Form (PDF)
- How-To Guide: Negative Balance (PDF)
Quality
Other
Credentialing and Demographic Updates
For Existing Network providers
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 of Tennessee CMS Final Rule 0057-F Prior Authorization Requirements: 70111 (PDF)
- Ambetter of Tennessee Prior Authorization Metrics Summary: 70111 (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.