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Ambetter of Tennessee Q2 2026 Newsletter

Date: 05/14/26

Mental Health Awareness Month

May begins Mental Health Awareness Month, a time when we are reminded of the daily challenges our healthcare providers encounter. Our team wants to offer support to our providers and administrative staff through various resources below. We encourage you to take a moment to explore the following links and disseminate the valuable information within your teams. These include the 988 document and information from the CDC, NAMI, AHRQ, and ACOG about physician burnout. Sharing may help a teammate navigate the complexities of your roles while prioritizing mental health.

Update for Procedure Codes S9083 and S9088 - Effective 8/1/2026

Effective 8/1/2026, the following procedure codes will become reimbursable when billed with place of service 20 (urgent care facilities). Claims submitted with another place of service will be denied, as these codes are not reimbursable for those locations.

  • Code S9083: Global fee urgent care centers
    • Represents a facility-level global urgent care service.
    • Indicates the member is physically seen in an urgent care setting.
  • Code S9088: Urgent care add-on code
    • Used only in addition to an E/M procedure code.
    • Indicates urgent care optional costs.
    • Used when services are provided in person in an urgent care setting.

If you have questions about the bulletin or other provider resources, please contact your Provider Relations Representative.

Implementation of Site of Care Optimization Program

Effective August 1, 2026, Ambetter Health will implement a Site of Care Optimization Program to support improved care delivery and cost-effectiveness for Ambetter Health members. Under this program, providers with members currently receiving infusions in outpatient hospital settings will be contacted to select an alternative home infusion or ambulatory infusion suite (AIS) option. Participating providers will receive outreach via fax or a phone call beginning in September. This outreach will request preferred site-of-care selections for individual members.

What is the Site of Care Program?

Our Site of Care program focuses on patients receiving infusion therapies or specialty drugs in high-cost setting, such as hospitals. The goal is to transition eligible patients to clinically appropriate lower-cost alternatives — like home infusion or freestanding infusion centers — when suitable.

This initiative focuses on therapies for conditions such as:

  • Immune globulin disorders.
  • Crohn’s Disease.
  • Rheumatoid Arthritis.
  • Psoriasis.
  • Multiple Sclerosis.
  • Rare Diseases.

Why This Matters

  • Improved patient Matters experience: Patients often prefer care closer to home or in lower-acuity settings, with greater comfort and convenience.
  • Reduced total cost of care: Shifting treatment to lower-cost sites may help reduce drug administration costs while maintaining high clinical standards.
  • Streamlined referrals: We offer support for identifying qualified alternative sites and facilitating transitions, minimizing administrative burden.
  • Better clinical alignment: This approach reflects industry best practices, payer expectations, and value-based models.

How You Can Help

  • Refer patients to in-network, lower-cost infusion sites when appropriate.
  • Engage with our team re: questions about eligibility or help with referrals.
  • Educate patients on their options and benefits of optimized site placement.
  • Share feedback on operational/clinical considerations to improve programs for success.

Need Assistance?

Our care coordination team can assist with patient identification, referral processes, and coverage considerations. Call us at (866) 861-6269. Together, we can enhance patient care while reducing healthcare costs across the system.

Member Eligibility Updates

Thank you for your continued partnership with Ambetter of Tennessee. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of changes to existing review criteria that will go into place on or after 7/1/2026.

Description of Changes:
Marketplace - Ineligible Member Recovery: CMS has identified members simultaneously enrolled in multiple marketplaces plans. According to ACA regulations members cannot be enrolled in more than one marketplace plan at the same time. Following CMS’s directives, we are required to retroactively terminate these memberships due to this violations of eligibility rules.

Payment Policies Updates

Effective on or after 8/1/2026, Ambetter of Tennessee will begin applying national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.

Both Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have documented that E&M services are among the most likely services to be incorrectly coded, resulting in improper payments to practitioners. The OIG has also recommended that payers continue to help to educate practitioners on coding and documentation for E&M services and develop programs to review E&M services billed for by high-coding practitioners.

Overview for Ambetter of Tennessee’s E&M Program:

  • Applies the relevant E&M policy and recoding of the claim line to the corrected E&M level of service.
  • Allows reimbursement at the highest E&M service code level for which the criteria is satisfied based on our comparative peer risk adjustment process.

According to the Federal Register and American College of Emergency Physicians, the level of service for the emergency department (ED) Evaluation and Management (E/M) codes is based primarily on the resources utilized by the facility and staff of the ED. Facility resources includes, but are not limited to, nursing time, clinical staff effort, supplies, equipment, and overhead directly related to the patient’s care, as distinct from the physician’s cognitive work. Professional E/M codes for providers are reported to capture the clinical complexity and intensity of the work preformed by the provider; however, E/M codes for facilities are reported for the amount and intensity of resources utilized by the facility to provide the care of the patient.

Policy Number: CC.PP.80
Policy Name: Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services

EX Codes:
• EXLc

Community Events

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

Risk Adjustment

Continuity of Care Plus

Ambetter of Tennessee is committed to supporting your efforts to provide the highest quality care to our members. As a result, we have launched our Continuity of Care (CoC) program for 2026. This initiative incorporates Appointment Agendas, HEDIS measures, and pharmacy metrics into one comprehensive view. The CoC+ program is designed to support your outreach to members 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 information on the CoC+ program and Provider Incentive Payout Bonus, please refer to your provider portal or your health plan representative.

Risk Adjustment Data Validation (RADV)

In June, Ambetter of Tennessee will be launching our annual RADV Audit Chart Chase Project, and we need your assistance in responding to a Department of Health & Human Services (DHHS) mandated audit. The DHHS initiates audits of health plans subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Tennessee is included in the audit and we, along with our contracted providers, must fully comply. Please prioritize the medical record requests coming from the vendor Optum.

Clinical Documentation Improvement (CDI) 2026 Webinar Series

Did you know? We offer Risk Adjustment, Coding and Documentation Education. Join us for discussions to help you optimize documentation and risk adjustment coding, Register here!

  • Learn practical risk adjustment strategies through real-world case studies
  • Strengthen documentation to capture the fill scope of each patient’s condition
  • Master the ICD-10-CM coding guidelines to ensure precise, compliant coding
  • Build confidence to document and code with accuracy that supports better outcomes

Live sessions built for providers, non-physician practitioners, coders, billers, and support staff, because great documentation and coding starts with a great team! Advanced registration is required. Utilize the corresponding registration link provided for each topic to register (links are unique to each webinar). If you have questions or need assistance with registration, email us at: CDIWebinars@centene.com.

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 effective 8/1/2026:

  • Infectious Disease: Respiratory Lab Testing (CG.CP.MP.01)
  • Pulmonary Function Testing (CP.MP.242)
  • Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181)
  • Applied Behavioral Analysis Documentation Requirements (CP.BH.105)
  • Biofeedback (CP.MP.168)
  • Concert Genetic Testing: Cardiovascular (V2.2025)
  • Concert Genetic Testing: Gastroenterology (V2. 2025)
  • Concert Genetic Testing: Hereditary Cancer (V2.2025)
  • Concert Genetic Testing: Multisytem Genetic Conditions (V2.2025)
  • Concert Genetic Testing: Neurology (V2.2025)
  • Concert Genetic Testing: Nutrition and Metabolism (V2.2025)
  • Concert Genetic Testing: Preimplantation Genetic Testing (V2.2025)
  • Concert Genetic Testing: Prenatal Screening (V2.2025)
  • Concert Genetic Testing: Transplant (V2.2025)
  • Concert Genetic Testing: Oncology: Algorithmic Assays (V2.2025)
  • Concert Genetic Testing: Oncology: Cancer Screening and Surveillance (V2.2025)
  • Concert Genetic Testing: Oncology: Hematology Malignancy (V2.2025)
  • Concert Genetic Testing: Oncology: Solid Tumor Molecular Diagnosis (V2.2025)
  • Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180)
  • Infectious Disease Gastroenterologic Lab Testing (CG.CP.MP.04)
  • Infectious Disease Primary Care & Preventive Lab Screening (CG.CP.MP.05)
  • Obstetrical Home Care Programs (CP.MP.91)
  • Outpatient Oxygen Use (CP.MP.190)
  • Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (CP.MP.174)
  • Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers (CP.MP.185)
  • Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (CP.MP.117)
  • Genetic and Molecular Testing (CG.PP.551A)
  • Concert Laboratory Payment Policy (CG.CC.PP.01)
  • Pancreas Transplant (CP.MP.102)
  • Home Births (CP.MP.136)
  • Tandem Transplant (CP.MP.162)
  • Assisted Reproductive Technology (CP.MP.55)
  • Lung Transplantation (CP.MP.57)
  • Applied Behavior Anaylsis (CP.BH.104)
  • Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200)
  • Deep Transcranial Magnetic Stimulation for the Treatment of obsessive Compulsive Disorder (CP.MP.201)
  • Heart-Lung Transplant (CP.MP.132)
  • Home Ventilators (CP.MP.184)
  • Concert Genetic Testing: Identify & Forensics (V2.2025)
  • Infectious Disease Genitourinary Lab Testing (CG.CP.MP.07)

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.

86Borders-Human Connections

Ambetter of Tennessee is partnering with 86Borders in a pilot project to support high-risk patients who are not consistently engaging in primary or preventative care. 86Borders is a member relationship and care coordination company that engages members through trusted, one-to-one outreach with coordinators who are based in Tennessee…not AI. This pilot runs through December 2026. Learn more below about how they work and their goals.

How 86Borders Supports Providers

Improves Patient Engagement & Visit Completion

  • Outreach to patients who have not been seen recently or who frequently use the ER
  • Assistance scheduling PCP and follow-up visits
  • Appointment reminders and barrier resolution to reduce no-shows

Supports Chronic Condition Management

  • Encourages patients to attend visits where ongoing conditions can be assessed
  • Reinforces medication adherence and preventative care
  • Helps patients understand the importance of regular primary care

Reduces Avoidable ER Utilization

  • Educated patients on appropriate site of care (urgent care vs ER)
  • Helps address drivers of ER use such as transportation barriers, medication access issues, or lack of PCP connection

Addresses Social Barriers That Affect Your Panel

  • Identifies needs such as food insecurity, housing instability, or financial challenges
  • Connects patients to community resources
  • Supports behavioral health and specialty referrals

Helps Maintain Accurate Network Information

  • Provides feedback to the health plan when
    • Panels are closed
    • Office locations or hours change
    • Access challenges are identified

By the end of the year, this pilot project focusing on high-risk patients hopes to: improve continuity of care and primary care utilization, support accurate evaluation of chronic conditions during visits, reduce avoidable emergency room visits, improve patient experience and engagement, and strengthen overall Quality performance.

Risk Adjustment

Wellcare Tennessee is committed to supporting your efforts to provide the highest quality care to our members. As a result, we have launched our Continuity of Care (CoC) program for 2026. This initiative incorporates Appointment Agendas, HEDIS measures, and pharmacy metrics into one comprehensive view. The CoC+ program is designed to support your outreach to members 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 information on the CoC+ program and Provider Incentive Payout Bonus, please refer to your provider portal or your health plan representative.

REMINDERS

  • 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.