Ambetter of Tennessee Q1 2026 Newsletter

Date: 03/06/26

HEDIS Season is Here!

It’s HEDIS time! Are you ready?

The Healthcare Effectiveness Data and Information Set (HEDIS®) provides a standardized set of measures from the National Committee of Quality Assurance (NCQA) to measure clinical quality performance. HEDIS® helps health plans and network providers to understand the quality of care being delivered to members, identify network performance gaps, and drive the design of programs and interventions to improve quality outcomes.

HEDIS Chart Retrieval for the 2025 season has started and will continue through May. During this period, our retrieval partners, Datafied and Datavant, will be contacting you on our behalf to request medical records. The priority measures for which we are requesting records include:

*Controlling High Blood Pressure (CBP)

*Colorectal Cancer Screening (COL)

*Eye Exam for Patients with Diabetes (EED/DRE)

*Glycemic Status Assessment for Patients with Diabetes (GSD)

*Kidney Health Evaluation for Patients with Diabetes (KED)

*Osteoporosis Management in Women who had a fracture (OMW)

*Transitions of Care (TRC-MRP, RDI, NIA)

*Care for Older Adults (COA-FS, MR)

*Cervical Cancer Screening (CCS)

*Immunizations for Adolescents (IMA)

*Childhood Immunization Status (CIS)

*Prenatal and Postpartum Care (PPC)

*Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

As more measures require Electronic Clinical Data Systems (ECDS) Reporting, we would like to collaborate with providers in our network. EMR Connectivity/Integration/SuDS Supplemental Data - Your partnership in Direct Remote EMR Access and/or Bi-Directional Feed is a great way to close care gaps, improve quality of care, and reduce administrative burden. There are significant benefits of remote access to patient charts, improving accuracy, completeness of patient data, and enhanced patient care.

Our goal is to ensure a seamless and efficient process throughout the season. Should you have any questions or concerns, please feel free to reach out to Brianna Birdsong, Project Manager (Quality_TN_Ambetter@CENTENE.COM).

Verifying Member Eligibility & Claims Risk

Thank you for the care you provide to our Ambetter of Tennessee 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 Tennessee member:

1. Member Eligibility Status
2. Premium Paid Through Date
3. Claims Paid Through Date

These items can be verified through Availity Essentials and other Ambetter of Tennessee 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 Tennessee Member Handbook.

Need Help?

If you have questions about eligibility verification, Grace Period rules, claims submission, or using Availity Essentials and the Ambetter of Tennessee portals, please contact your Provider Engagement representative.

Evolent Authorization Code Updates

In partnership with Evolent, Ambetter of Tennessee is removing select Evolent-related procedure codes from prior authorization to improve the overall provider experience. These codes will be removed on or after 4/1/2026.

Find a Provider-New Search Functionality

Enhanced search capabilities are now live in the Ambetter of Tennessee Find a Provider tools, making it easier and faster for users to locate the right providers!

• Condition-to-Specialty Search allows users to enter a symptom and receive specialty suggestions directly in the search dropdown based on that symptom. This enhancement helps users more easily identify the appropriate services by guiding them to specialties related to their primary concern. As we gather feedback and usage data, we will continue working with our vendor partner to expand the list of condition terms and further refine the search experience.

• Popular Search Suggestions displays commonly used searches in the dropdown when users begin typing one of the established terms featured in the Popular Search section of the search page (e.g., Primary Care or Routine Dental). This provides an additional, convenient way to initiate a predefined search, reducing both decision-making and the number of clicks needed to find relevant providers.

Ambetter Health Solutions

Ambetter of Tennessee rolled out a new network effective January 1, 2026.  The new network is known as Ambetter Health Solutions which is under our standard Marketplace-Exchange product. The Ambetter Health Solutions network exclusively services the Individual Contribution Health Reimbursement Arrangement (ICHRA) market, an employer-sponsored approach to access health insurance options for employees through Marketplace products.   

Under Ambetter Health Solutions plans, providers are able to track these members through a unique member card.  Ambetter Health Solutions members will experience the wide array of coverage and perks available to current Ambetter members such as the Ambetter Health App, Pharmacy Program, Virtual 24/7 Care, and Care Management Services. 

Please Note: As a current Ambetter provider, there is nothing you need to do to be part of this network and see new Ambetter Health Solutions members after January 1, 2026.

Risk Adjustment

Risk Adjustment - Chart Chase Season

Ambetter of Tennessee is currently in the 2025 Date of Service (DOS) Risk Adjustment Chart Chase Project, running from October 2025 through April 2026. Your timely participation is essential to ensure accurate data collection and improved member outcomes. Please prioritize all medical record requests from our designated vendor, Datavant. Thank you for your continued partnership, and here’s to a successful chart chase season!

Risk Adjustment (Continuity of Care Plus)

Ambetter of Tennessee remains committed to supporting providers in delivering high‑quality care to our members. As part of that effort, we are excited to introduce the 2026 Continuity of Care Plus (CoC+) Program, launching in February 2026. 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.

Policy Updates

Clinical Policies

Ambetter of Tennessee has recently updated select clinical policies with some added criteria requirements that may impact the prior authorization process. Please see the revision log within each policy to review the changes. This Clinical Policy Updates page reflects upcoming clinical policy changes. Please refer to this page for recent policy updates and reach out to your Provider Relations representative if you have any questions. For a list of all active clinical policies, visit the Clinical & Payment Policies page.

The following policies had updates that will be effective 5/1/2026:

• Electric Tumor Treating Fields (CP.MP.145)
• Facility Based Sleep Studies for Obstructive Sleep Apnea (CP.MP.248)
• Pediatric Oral Function Therapy (CP.MP.188)
• Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185)
• Transplant Service Documentation Requirements (CP.MP.247)
• Ultrasound in Pregnancy (CP.MP.38)

Pharmacy Policies

In a continuous effort to make it easier to do business with us, Ambetter of Tennessee has added pharmacy policies to their Clinical & Payment Policies page. Please refer to this page for policy updates and review the revision log within each policy to view any policy changes.

Community Events

Ambetter of Tennessee is committed to supporting our community.  Below are three events that we supported within Tennessee 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.

Memphis-Shelby County Schools (MSCS) Community Resources & Career Event

United Way Community Event - Memphis

Fall Psychiatric Symposium 2025-Knoxville

Medicare Open Enrollment Period is Underway - Here’s How You Can Help Your Patients

Medicare Open Enrollment (OEP) is now underway through March 31, giving eligible patients a chance to review and adjust their Medicare coverage based on their current care needs.

Our provider partners play an important role during this time, especially if a member’s health needs have changed.

Here’s how you can support patients during OEP:

• Ask if they’re confident in their current coverage.
• Encourage them to review benefits related to medications, specialists and care needs.
• Remind eligible patients of the March 31 deadline to make changes to their existing plan.

Any changes made during OEP will take effect according to Medicare guidelines. Patients can learn more or get help reviewing their options at medicare.gov or by calling Wellcare at 1-800-225-8017 (TTY 711).

Evolent Authorization Code Updates

In partnership with Evolent, Wellcare is removing select Evolent-related procedure codes from prior authorization to improve the overall provider experience. These codes will be removed on or after 4/1/2026.

Find a Provider-New Search Functionality

Enhanced search capabilities are now live in the Wellcare Find a Provider tools, making it easier and faster for users to locate the right providers!

• Condition-to-Specialty Search allows users to enter a symptom and receive specialty suggestions directly in the search dropdown based on that symptom. This enhancement helps users more easily identify the appropriate services by guiding them to specialties related to their primary concern. As we gather feedback and usage data, we will continue working with our vendor partner to expand the list of condition terms and further refine the search experience.

• Popular Search Suggestions displays commonly used searches in the dropdown when users begin typing one of the established terms featured in the Popular Search section of the search page (e.g., Primary Care or Routine Dental). This provides an additional, convenient way to initiate a predefined search, reducing both decision-making and the number of clicks needed to find relevant providers.

Risk Adjustment

Continuity of Care Plus

Wellcare TN remain committed to supporting providers in delivering high‑quality care to our members. As part of that effort, we are excited to introduce the 2026 Continuity of Care Plus (CoC+) Program, launching in February 2026. 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.

REMINDERS

• Ambetter of Tennessee 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/tn.
• Learning Opportunities: Provider Information Sessions are offered monthly on every 3rd Friday at 1 PM CT/2 PM ET.
• Remember to submit any demographic updates to Provider Engagement - click for document.

Do you have any suggestions for our newsletter? Email Amber Neal.