Q1 2024 PROVIDER NEWSLETTER

Date: 02/12/24

Membership has grown!

We are very excited to announce that our Ambetter marketplace membership is nearing 300,000 across Tennessee. Most of you have been with us since 2019 when we launched in targeted counties, grown membership year over year, and added counties until we were statewide in 2023. We are forever grateful to you as our partners across Tennessee delivering care to our historically underserved and uninsured population.

Has your facility grown? Sending your full roster in one document and any changes or updates in a separate document ensures that we can quickly identify and get the necessary updates submitted in a timely manner. This format will also help make sure no updates are missed. Please reach out to your Provider Engagement Administrator if a roster template is needed. 

We are excited about building new partnerships and serving our members throughout 2024 and beyond. 

Community Collaboration

Ambetter of Tennessee participated with the US Small Business Administration to support partners & individuals affected by the December tornadoes. We are proud to connect with the communities we serve and look forward to building more long-term relationships in the future. 

Provider Resources

With one CLICK you are able to scroll down to find a variety of resources such as the Provider & Billing Manual, Quality Improvement & Risk Adjustment documents, Prior Authorization forms, and Behavioral Health information.

Cultural Humility & Health Equity resources can be found here

In addition to a variety of documents & resources mentioned above, we also made it easy to email the right department for the right reason. We hope listing these email addresses makes it easy for you to contact the right person.

New contract requests go to ambettertnnetwork@centene.com

Updates to pre-existing contracts, including requests to add/term practitioners and data maintenance/enrollments should be sent to ambettertnops@centene.com.

Clean Claims Review

Coming soon, we will be migrating our Clean Claims review process from Optum to 6 Degrees Health. They will provide a detailed review of line-item claim data and coding to evaluate for errors and inconsistencies in billing.

• Prepay review on high dollar, IP hospital claims 
• UB (claim) and Itemized Bill (IB)
• Contains required documentation to properly adjudicate and pay the claim
• Claim lacks defects and improprieties

Billing & Clinical Policy Updates

Hemodialysis Modifier – Post Pay Recover Program Effective 5/1/2024
Ambetter of Tennessee will target and begin recoupment of paid hemodialysis claims (CPT 90999) where modifier G1-G6 is not present on the claim based on CMS Hemodialysis billing requirements. Reach out to your Provider Engagement Administrator if you have questions.

For claims received on or after *10/17/2023*, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement. 

HEDIS & Risk - Chart Chase Season

Ambetter of Tennessee is currently active for both the HEDIS and Risk Adjustment chart chase projects. The HEDIS Hybrid Project runs from late January through April annually. Risk Adjustment Chart Chase runs from October through April. Your active participation in these projects is crucial for accurate data collection and to improve quality care outcomes. We ask that you please prioritize the medical record requests which will be coming from the vendors listed below. Here's to a successful chart chase season!

Retrieval Vendors in use:

• Datafied 
• Ciox (Datavant)

Please do not hesitate to reach out with any questions.

EMR Connectivity/Integration/SuDS Supplemental Data - Your partnership in Direct Remote EMR Access and/or Bi-Directional Feed is a great way to close Quality and Risk Adjustment care gaps, improve quality of care, and aims to reduce administrative burden. 

Upcoming Provider Orientations

The 2024 Provider & Billing Manual is your comprehensive guide to doing business with Ambetter of Tennessee. The manual includes a wide array of important information relevant to providers including, but not limited to: Network information, Billing guidelines, Claims information, Regulatory information, Key contact list, Quality initiatives…and much more!

The Ambetter of Tennessee Provider Engagement staff conducts monthly Provider Orientations via Zoom to review topics such as the secure provider portal, prior authorizations, claims, billing, payments, grievances, appeals, and much more. The dates for the upcoming orientations can be found below. If you are interested in attending, please contact your designated Provider Engagement Administrator.

• February 21st, 2024 at 1pm CST
• March 20th, 2024 at 10 am CST
• April 17th, 2024 at 1pm CST 
• May 15th, 2024 at 10am CST

Appointment Availability & Wait Times

Ambetter follows the accessiblity and appointment wait time requirements set forth by applicable regulatory and accrediting agencies. Ambetter monitors participating provider compliance with these standards at least annually and will use the results of appointment standards monitoring to ensure adequate appointment availability and access to care and to reduce inappropriate emergency room utilizations. The table below depicts the appointment availability for members: 

REMINDERS

• February is American Heart Month - “Heart Smart” fact sheet
• March is National Colorectal Cancer Month
• Schedule a 1:1 walk-through highlighting all features & functions found in our Secure Provider Portal.
• Remember to contact your Provider Engagement Administrator with any demographic updates.
• Providers can create an account or login to our portal HERE.