Q4 2024 Provider Newsletter

Date: 12/16/24

PREMIER & SELECT Changes in 2025

Ambetter is grateful for your participation in our provider network and the care you provide our members. Each year, we conduct a comprehensive review of our market operations and footprint to best align our network strategy and resources. We want to share two network updates coming up in 2025.

• As of January 1, 2025 the Select plan in Tennessee will be discontinued. We are committed to ensuring you have all the resources available to make this transition as smooth as possible for you and your patients.

• Beginning January 1, 2025 the Bronze | Silver | Gold network will be renamed to the PREMIER network. Members will be notified through various upcoming notifications and will see this change on Ambetter Guide.

While our plan offerings are changing, our commitment to delivering quality care and services to our members is unwavering. If you want to learn more you can read our recent press release here. Thank you for your continued partnership as we work to transform the health of the communities we serve, one person at a time. 

Availity Portal Goes Live Monday, November 18th

Ambetter of Tennessee has chosen Availity Essentials as its new, secure provider portal. Starting Monday, November 18th, you can validate eligibility and benefits, submit claims, check claim status, submit authorizations, and access Ambetter of Tennessee payer resources via Availity Essentials. Live training opportunities are listed below. Please Note: You must be logged into your Availity Essentials account to register and attend live training.

You can log in to your existing Essentials account (https://apps.availity.com/availity/web/public.elegant.login) to enjoy these benefits for Ambetter of Tennessee Plan’s members beginning November 18th. Our current secure portal will still be available for other functions you may use today.

If you are new to Availity Essentials, getting your Essentials account is the first step toward working with Ambetter of Tennessee on Availity.  Your provider organization’s designated Availity administrator is the person responsible for registering your organization in Essentials and managing user accounts. This person should have legal authority to sign agreements for your organization. If you are the administrator, you can register and get started with Availity Essentials at https://www.availity.com/documents/learning/LP_AP_GetStarted/index.html#/

Enroll in a Live Training:

Instructions to enrolling for a provider webinar in the Availity Learning Center(ALC):   

1. Log in to Availity Essentials.
2. Select Help & Training > Get Trained.
3. ALC opens in a new browser tab. If it does not, have the user check their browser settings to allow for pop-ups and redirects from apps.availity.com and availitylearning.learnupon.com
4. Select the Sessions tab.
5. Select the View Course button next to the webinar.
6. Select the Enroll button.

Live Training Topics and Dates:

*Availity Essentials Introduction

• Monday, Nov. 18 – 3 p.m. EST
• Monday, Dec. 2– 2 p.m. EST

*Authorization Tools

• Tuesday, Nov. 19 – 2 p.m. EST
• Tuesday, Dec. 3 – 12:30 p.m. EST

*Claim Submission

• Wednesday, Nov. 20 – 11 a.m. EST
• Wednesday, Dec. 4 – 12 p.m. EST

*Claims Follow-up Tools

• Thursday, Nov. 21 – 3:30 p.m. EST
• Thursday, Dec. 5 – 1 p.m. EST

*Risk & Quality Applications

• Thursday, Nov. 21 – 11 a.m. EST
• Tuesday, Dec. 4– 10:30 a.m. EST

If you need additional assistance with your registration, please call Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday, 8 a.m. – 8 p.m. ET.  

Did you know? 

Our 2025 Provider Manual is ready! You can find a variety of resources on this page including the current 2024 Provider Manual, Quality and Risk Adjustment resources, and various provider education.

Do you have new providers or any changes we need to know about to ensure accurate & timely payments? Submit any demographic updates to your Provider Engagement Administrator - click for document  

We’ll be at the Nashville Walk to End Alzheimer’s on Saturday, November 9th - hope to see you there!

If you ever want to see previous announcements and newsletters, you can easily find all of them in one place by looking at our Provider News webpage.

Katherine Bell-Anthony is the Director, Clinical Operations - email her for any issues with Authorizations or Case Management related questions.

katherine.bell-anthony@centene.com

Are you in the Knoxville area? Come visit us at the end of November at the Fall Psychiatric Symposium or the Rural Health Association of Tennessee Annual Conference. 

Provider Summits were a Success!

Wellcare and Ambetter of Tennessee held its first Provider Summit of 2024 this summer. The eventful Provider Summit offered a variety of insightful topics including CAHPs, current quality initiatives and Clinical Documentation Improvement.

Our attendees in both Memphis and Smyrna engaged in one-on-one time with the Ambetter Senior Leadership Team: Miranda Grubb, Vice President of Quality; Dr. Crigler, Chief Medical Officer; and Heath Phillips, Wellcare and Ambetter of Tennessee Health Plan President & CEO (above, center). Next to Heath is Melissa Jones, Program Manager on the left and Eunice Hubbard Woods, Quality Practice Advisor on the right. The group picture on the right was taken at the Smyrna event.

The open dialogue with our provider partners during the summits in both West and Middle Tennessee provided an opportunity to reinforce our company’s values of Accountability, Courage, Curiosity, Trust, and Service. 

Quality Improvement

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 will take place from February 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),  Cervical Cancer Screening (CCS), Immunizations for Adolescents (IMA), Childhood Immunization Status measure (CIS), Eye Exam for Patients with Diabetes (EED), Glycemic Status Assessment for Patients with Diabetes (GSD), Prenatal and Postpartum Care (PPC), and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC).

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).

Care Kits Pilot Program

Objective: To assist Ambetter of Tennessee members with diabetes in closing care gaps related to health and wellness, particularly focusing on high-risk members with significant Drivers of Health (DOH) needs.

Background: In October 2023, Ambetter of Tennessee distributed Care Kits to 506 members identified as having open HBD (Hemoglobin A1c) care gaps. These kits included essential tools and resources aimed at empowering members to manage their health effectively. The initiative reflects Ambetter's commitment to improving health outcomes by addressing both clinical needs and social determinants impacting member health.

Target Population:

• Total Members: 506 noncompliant diabetic members within the HBD population.
• Criteria: Members prioritized based on open HBD care gaps and high DOH risks.

Measures of Success

Success of the pilot will be evaluated based on the improvement rates in the following HEDIS measures:

• HBD (Hemoglobin A1c): Monitoring and management of blood glucose levels.
• EED (Eye Exam): Regular eye examinations to detect diabetic retinopathy.
• KED (Kidney Health Evaluation): Screening for kidney function and disease management.
• Preventative Visits: Engagement in routine healthcare appointments.

Outcomes

1. HBD Compliance:
   • 64% of compliant Care Kit members (58 out of 90) achieved HbA1c compliance post-receipt of the kit.
2. EED Compliance:
   • 36% of compliant Care Kit members (36 out of 99) completed an eye exam post-receipt.
3. KED Compliance:
   • 60% of compliant Care Kit members (70 out of 117) gained compliance post-receipt.
4. Preventative Visits:

5% of all care kit recipients (25 members) attended a preventative visit after receiving the kit.

Recoupment of Overpayments

Ambetter of Tennessee’s 2025 Provider Billing Manual will be updated with information regarding compliance with the amendments made to Tennessee Code Annotated § 56-7-110.

Ambetter Health Day in Antioch

We had a fantastic community event serving over 400 community members in Antioch this summer. If you would like to partner with us on community events, please contact Trillo Shipman, Director of Community Relations.

Revised Clinical Policies

Ambetter of Tennessee has recently updated select clinical policies with some added criteria requirements that may impact the review of a prior authorization. Please see the revision log within each policy to review the changes. This Clinical Policy Update 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.

FarmboxRx Diabetic Program

Ambetter of Tennessee is partnering with FarmboxRx to provide healthy food and wellness resources to members recently diagnosed with diabetes.

Ambetter of Tennessee’s Diabetic Care Program is here to support members with managing diabetes. Eating healthy foods, living an active lifestyle, and regular doctor visits improve the quality of life. Members will also be encouraged to close HEDIS Care gaps.

What Members Can Expect:

• FarmboxRx will deliver 2 food boxes to members this year: The first box of fresh fruits and vegetables shipped in September 2024. A second box of ready-to-heat meals will ship in November 2024. Plus, health and wellness tips are included in each delivery.
• Expect a Friendly Check-in. The FarmboxRx Member Care Team will reach out to the member. This call is meant to support completion of important health screenings.
• Take Action Now. Members are asked to call their doctor’s office and schedule the following tests and screenings: A1c Test, Eye Exam, Blood pressure, and Urine test.
• Bonus Food Box! Members have a chance to get another food box after completing a survey over the phone. The FarmboxRx Member Care Team may reach out to them at the end of the program to complete the survey.

Look for more great ways we will be supporting our diabetic members in 2025. If you have questions about the program, please reach out to Regina Everett. 

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 through April. 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 becoming from the vendor Datavant (formerly CIOX). Here's to a successful chart chase season!

ER Diversion/Care Gap Kicker (Continuity of Care/CoC)

Ambetter has launched an ER Diversion & Care Gap Kicker campaign for members with multiple ER visits. Providers are eligible for an extra $100 for completing additional sections on the Appointment Agenda. $100 is in addition to Continuity of Care bonus for assessing and closing Risk Gaps. Please refer to your provider portal or your health plan representative. Existing CoC submission deadline is January 31, 2025 for 2024 DOS. The ER Diversion & Care Gap Kicker campaign submission deadline applies through the end of 2024.

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 2024. 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. Please refer to your provider portal, your health plan representative, or 2024 COC Program Review (PDF). You can learn more about our resources on our website. Scroll down to the Risk Adjustment section to find the Continuity of Care (CoC) program description and the Tiered Incentive Payments explanation.

Risk Adjustment Data Validation (RADV)

We have officially launched 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 HHS 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.

EMR Access & Supplemental Data Feeds

Did you know? Your partnership in granting remote EMR (Electronic Medical Records) access and/or a Bi-Directional Data Feed is the most direct and efficient way to close Quality and Risk Adjustment care gaps, improve quality of care, and reduce administrative burden. For more information on the benefits of remote access and improving accuracy/completeness of patient data or to get started, please review the SUDS document (PDF).

Payment Initiatives

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. The claim review and edit below will be implemented on or after 2/1/2025.

Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members. 

REMINDERS

• Open enrollment is here! It begins in Tennessee today November 1st, 2024 and goes through January 15th, 2025.
• Remember to submit any demographic updates to Provider Engagement - click for document

Do you have suggestions for our newsletter? Please email Chandra Green.