Q2 2025 Provider Newsletter

Date: 06/13/25

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.

• 988 document
• CDC support for health professionals
• NAMI & health care professionals
• AHRQ - physician/clinician burnout
• ACOG - are you aware of your own mental health?

Prior Authorization & Fee Schedule Updates

Effective August 1, 2025, the following codes will require prior authorization to be submitted to Ambetter of Tennessee.

31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
31298 Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia
31295 Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, trans nasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium

Ambetter Fee Schedule Modifications, Effective 8/1/2025:

• Telehealth Modifier 95 will be priced at facility rates to align with all other telehealth pricing (POS 11 only)
• Payments for midlevel services (Nutritionist/Dietician/Midwife) will be modified to align with CMS pricing

If you have questions, please contact Provider Services.

Learning Opportunities

We are excited to launch our monthly Provider Information Sessions, designed to keep you informed on key topics that directly impact your practice and patient care. Our goal is to ensure these sessions provide valuable insights that support you in delivering the best possible care while also improving overall provider satisfaction, high quality patient care and enhancing CAHPS results. We invite you to join us every third Friday at 1 PM CT/2 PM ET for a new topic designed to keep you informed on key subjects that directly impact your practice and patient care.

Join us via Microsoft Teams
Microsoft Teams
Join the meeting now
Meeting ID: 239 151 018 933 Passcode: cU7jC6vj

Dial in by phone
+1816-702-6560,,812372069# United States, Kansas City
Phone conference ID: 812 372 069#

Join on a video conferencing device
Tenant key: centenecorp@m.webex.com Video ID: 113 738 765 4

Availity Editing Services

In a continuous effort to make it easier to do business with us, Ambetter of Tennessee has introduced Availity Editing Services (AES). Centene has partnered with Availity to return rejection messages on its behalf via AES messages.

AES can identify a claim error upfront and return a message to you for correction before sending the claim on to the plan to be adjudicated. You should review edit messages for potential corrections to the suggested claim line(s). If you make updates to the claim, this may help the claim process correctly the first time, preventing errors, improving payment accuracy, and claims adjudication turnaround time. If, after reviewing the message, you find it does not apply, please resubmit the claim as-is and this will allow a bypass of the edit in cases where it may not be applicable. This is not intended as a new method to deny a claim, nor does it bypass or replace downstream edits.

If you submit claims via Availity, learn how to gather your reporting by joining one of Availity’s free webinars to learn additional tips for streamlining your workflow:

• Send and Receive EDI Files – Training Demo
• EDI Reporting Preferences – Training Demo

If you need assistance with registering for Availity Essentials, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET. For general questions, please reach out to your Provider Engagement Representative or contact us at ProviderRelationsTN@Centene.com.

Elective Medical Inpatient Authorization Process Change

To provide increased flexibility and better align with industry best practices, we made the following changes to our planned/elective medical inpatient authorization process effective May 1, 2025.

• Prior authorizations for planned/elective inpatient services will be approved for professional services by issuing an outpatient (OP) authorization.
  • Elective Inpatient Prior Authorization numbers will now start with the prefix of OP instead of IP (i.e., OP123456789).
  • The authorization will indicate approval at the inpatient level of care.
  • With the approved OP authorization, there will be an authorization time span of 90 days in which the services can be performed.
• Authorizations for the inpatient stay (IP authorization) will be processed and issued at the time of admission.
  • There is no need to get an IP authorization prior to the date of service. Services can be rendered anytime within the authorization time span.
  • Notification of admission is required within one business day of admit. At the time of admission notification, an additional authorization number for the admission will be provided to the facility with the IP prefix (IP Authorization).

As a reminder, all planned/elective admissions to the inpatient setting require prior authorization. Prior authorization should be requested at least five (5) days before the scheduled service delivery date or as soon as need for service is identified. If prior authorization is not on file at the time of planned/elective admission, the service is considered retrospective, and provider should follow the appropriate retrospective request process.

Thank you for continuing to provide our members with high quality and compassionate care. If you have questions regarding the information contained in this update, please contact your Provider Engagement Specialist.

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.

Sista Strut - Memphis
Ambetter of Tennessee was in attendance for the Sista Strut this April in Memphis. Along with about 8,000 others, we showed our support by sponsoring the Survivor Wall of Fame, where survivors can sign their names to honor and recognize their journey with breast cancer.

March for Babies Walk
On April 19, we were a proud Silver sponsor for the annual March for Babies Walk. It was a great event with a great turnout. If you are not familiar with the March for Babies mission, it is to prevent birth defects and premature birth.

Quality Improvement

Ambetter of Tennessee will be collaborating with 86Borders to improve health outcomes and plan performance through deep, personal engagement, supporting the resolution of members’ complex social and clinical needs by addressing the members’ SDoH needs. Soon 86Borders will contact selected members to participate.

This program will leverage 86Borders' expertise in member relationships and care coordination to achieve measurable improvements in key quality metrics.

Objectives:

• Increase gap closures for selected HEDIS measures.
• Active direct gap closure solution for SNS-e HEDIS measure.
• Enhance screening and management for members with diabetes and hypertension.
• Improve engagement with the health plan and primary care.
• Provide education related to gap closure and appropriate Utilization.

If you have any questions, please contact Tamaya Cylear.

Risk Adjustment

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 launch 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.

Risk Adjustment Data Validation (RADV)
In June, we 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) 2025 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 how to stay compliant with regulatory requirements
• Learn compliant coding practices and accurately capture a patient’s complexity
• Learn to identify elements to support code assignment
• ……And more!

Live risk adjustment education tailored for healthcare providers, non-physician providers, coders billers, administrative and support staff. 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 8/1/2025:

CP.MP.62 Hyperhidrosis Treatments

CP.MP.107 DME

CP.MP.180 Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

CP.BH.104 Applied Behavioral Analysis

CP.BH.105 Applied Behavioral Analysis Documentation Requirements

CP.MP.142 Urinary Incontinence Devices and Treatments

CP.MP.57 Lung Transplantation

CP.MO. 69 Intensity-Modulated Radiotherapy

CP.MP.132 Heart-Lung Transplant

CP.MP.176 Outpatient Cardiac Rehabilitation

CP.BH.200 Transcranial Magnetic Stimulation for Treatment of Major Depression

CP.BH.201 Deep Transcranial Magnetic Stimulation for Treatment of Obsessive Compulsive Disorder

CP.MP.247 Transplant Service Documentation Requirements

CP.MP.147 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention

CP.MP.185 Skin and Soft Tissue Subtitles for Chronic Wounds with Changes

HIM.CP.BH.500 Behavioral Health Treatment Documentation Requirements

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

RxEffect Bonus Incentive for Wellcare Tennessee and Ambetter of Tennessee Providers

We are excited to announce that we are contracted with RxAnte to provide the RxEffect program to our Tennessee providers. RxEffect is a web-portal which provides real-time member adherence status to Medicare & Marketplace Providers. The RxEffect program utilizes predictive modeling to identify patients at-risk for non-adherence and provides daily pharmacy claims updates to equip Providers to easily identify members who require medication support. The exciting piece is there will be financial incentives* paid to Providers who use RxEffect to identify and take action with members’ medication therapies.

*Financial incentive (Incentive Payment Program) payments would apply to providers who use RxEffect® to identify and take action in the following Star ratings medication therapy areas: Diabetes, blood pressure, and cholesterol to achieve final fill adherence status.

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 for more information.

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