Q1 2025 Provider Newsletter

Date: 02/17/25

Quality Improvement

HEDIS season has started!

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)
• Glycemic Status Assessment for Patients with Diabetes (GSD) 
• Cervical Cancer Screening (CCS)
• Immunizations for Adolescents (IMA)
• Childhood Immunization Status (CIS)
• Eye Exam for Patients with Diabetes (EED)
• 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 aims to reduce administrative burden. There are significant benefits of remote access to patient charts, improving accuracy, completeness of patient data, and enhanced patient care. For more information or to get started, please review the SUDS document (PDF).

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 Jeanette Walls, HEDIS Project Manager (Quality_TN_Ambetter@CENTENE.COM).

CAHPS:

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a survey tool that asks members to evaluate their experience with their health plan and providers’ offices. CAHPS is an annual survey administered to an anonymous, random sample of members (February/March – June). For Ambetter, it is known as the Qualified Health Plan Enrollee Experience (QHP EE) survey. The survey is used to evaluate consumer experiences and how members perceive key aspects of the care they received in the last six months. CAHPS participation is a CMS requirement for Medicare Star Ratings and Marketplace Quality Rating System (QRS). It is also a National Committee for Quality Assurance (NCQA) requirement for health plan accreditation and Health Plan Rating System (HPR). Each of these rating systems are publicly reported. The following are the provider-influenced measures and their weight.

Impactable Program Measures:

• Flu vaccine
• Care coordination
• Getting appointments and care quickly
• Getting needed care
• Rating of personal doctor
• Rating of health care quality

What we know: Positive Patient Experience Improves:

• Clinical outcomes.
• Care coordination.
• Patient engagement in their own care.
• Patient loyalty.
• Medication adherence.
• Ratings. 

We are committed to partnering with our providers to deliver an outstanding patient experience. As a provider, you are the most critical component of that experience. We want to ensure that you know exactly how your patients are evaluating your care.

Please encourage your patients to complete the survey when received. We value their feedback.

Risk Adjustment

Risk Adjustment - Chart Chase Season

Ambetter of Tennessee is currently active for our 2024 DOS Risk Adjustment Chart Chase project. The project runs from October 2024 through April 2025. Your active participation 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 vendor: Datavant. Here's to a successful chart chase season!

Risk Adjustment (Continuity of Care/CoC)

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 2025. 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 visits and condition management, which will help us better identify members who are eligible for case management. 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 (Continuity of Care Plus/CoC+ Gaps &Insights)

Introducing the launched of Continuity of Care Plus (CoC+) Gaps & Insights for members identified as high utilizers or with multiple ER visits. Providers are eligible for an extra $100 for completing additional sections on the Appointment Agenda. $100 is in addition to the CoC bonus for assessing and closing Risk Gaps. Please refer to your provider portal or your health plan representative.

Community Events

Our team recently participated at the 2024 Walk to End Alzheimer’s this past fall in Nashville. We secured a vendor table for the event spotlighting our health plan brand and sponsorship for this fundraiser. Members of our Centene team participated as walkers for this event enjoying all the festivities, music, and fitness.  

Dianna Clarke, Director of Provider Relations (bottom photo, second from the left), especially liked the interactive memorial flower garden where you could write a commemorative note or blessing for those impacted by this disease on a windmill garden flower to add to their garden or yours. 

On November 15, 2024, members of our team attended the Mercy 25th Anniversary Silver Gala—what a treat to participate in this grand event. The Centene Team from Middle Tennessee polished up for an evening of fundraising, networking, music, and dancing at The Factory in Franklin. The auctions were the star of the show as our Mercy Health Partners met their goal for the upcoming year.  

If you would like to partner with us on community events, please contact Trillo Shipman, Director of Community Relations.

Claims & Appeals Timeframe

Ambetter of Tennessee is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary upfront rejections or denials.

Please see our 2025 Provider Manual (PDF) for more information.

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.

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. 

Pharmacy Network Update

Ambetter of Tennessee is always focused on making sure our members receive the highest quality care at the lowest premium. One way we do this is by monitoring our pharmacy network performance. To provide our members with the lowest possible premium for 2025, CVS retail and certain other select retail pharmacies were no longer chosen to participate in our network as of 1/1/25. Our members still have access to Walgreens and independent Pharmacies as in years past.  We realize that our providers are the front line for our member interactions, so we wanted to remind our network providers of the pharmacy decision in 2025.

Secret Shopper 

As of January 1, 2025, the Centers for Medicare & Medicaid Services (CMS) requires providers to meet appointment wait time standards to ensure enrollees seeking an appointment can schedule an appointment with the time frames below. The secret shopper survey will be conducted for primary care (routine) and behavioral health providers. A third-party entity will be conducting the secret shopper surveys between January 1, 2025 and May 31, 2025.

REMINDERS 

• Beginning January 1, 2025 the Bronze | Silver | Gold network was renamed to the PREMIER network. Members were notified through various notifications and will see this change on Ambetter Guide.
• Remember to submit any demographic updates to Provider Engagement