News
Ambetter of Tennessee Q4 2025 Newsletter
Date: 11/14/25
Veteran’s Day 2025
Veteran’s Day, which is observed annually on November 11, is a notable time to recognize and give gratitude for the sacrifice, bravery, and service of veterans. November 11 marks the anniversary of the end of World War I and was renamed Veteran’s Day in 1954 to honor all American Veterans. It serves as a day to honor all those who have fought for all the freedoms and rights that we enjoy today. By honoring veterans, we contribute to a culture of respect and appreciation for their service.
Ways to Honor Veterans:
- Thank a Veteran for Their Service: Expressing gratitude is a simple task that can go a long way in making a veteran feel appreciated.
- Volunteer Your Time and/or Resources: There are multiple organizations that support veterans and their families & volunteering can make an impact in their lives.
- Attend Ceremonies: See what your community does to show their support to their veterans. Many host parades or memorial services that are open to the public.
- Educate Others: Raising awareness and sharing the history and significance of Veteran’s Day helps to ensure that their legacy is remembered and celebrated.
Open Enrollment
Ambetter of Tennessee open enrollment went live 11/1/2025. Visit our website for Ambetter of Tennessee’s open enrollment product overview.
2026 Billing Changes
Interim Billing
Effective January 1, 2026, Ambetter of Tennessee will deny interim billing claims. It is the policy of Ambetter Health not to accept interim billing for estimated monies owed to participating and non-participating facilities. Claims processing will begin upon receipt of the bill for total services rendered.
- Ambetter Health requires that participating and non-participating Providers submit final claim upon Members discharge from facility.
- Interim billing will not be accepted for Per Diem, DRG and Billed Charges reimbursement. The claim will be denied until the claim with the first date of admission through the date of final discharge is received.
Enhanced Diabetes Care Silver Plan
November begins Diabetes Awareness Month, which is observed each year to raise awareness surrounding diabetes and how it impacts millions of people. Diabetes is one of the fastest growing chronic diseases in the world, affecting nearly one in two Americans. This November marks the 85th Anniversary of the American Diabetes Association, who works to emphasize the importance and need for education surrounding this chronic disease.
Within Ambetter of Tennessee, we are excited to announce that our Enhanced Diabetes Care Silver Plan is returning. The product (Enhanced Diabetes Care Silver with $0 Drugs Options) will also allow for a Vision and Dental buy up. As a reminder, this is a condition-specific plan with enhanced benefits and cost savings for ongoing diabetes management and treatment. For those members selecting our Enhanced Diabetes Care Silver Plans, they will have $0 copays on preferred insulin, certain medications, supplies, labs and clinical support to help manage their diabetes.
Important Prior Authorization Update
Effective February 1, 2026
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Ambetter of Tennessee wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details can be found below. These changes may include:
- Removing PA requirements based on criticality of review and clinical need.
- Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.
If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.
| Service Category | PA Rule | Services | Procedure codes |
|---|---|---|---|
| DME Services | No PA Required | Wheelchairs | E1140, E1150 |
| Surgery Procedures | PA Required | Digestive System | 43281, 43282, 49329 |
| Male Genitalia | 55866 | ||
| Musculoskeletal System | 28300, 28308 |
Billing & Payment Updates
Optum CPI
As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim review. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after 2/1/2026, providers my 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.
| Editing Area | Description |
|---|---|
| Trauma Activation with No Ambulance Service | This analytic will identify outpatient claims with revenue codes for trauma response (Rev 681 – 689) when there are no claims in history for ambulance services with HCPCS codes between A0021 and A0999 for the same member on the same date of service. |
| High Dollar Hardware | This analytic identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws). |
| Unsupported Lab Tests on High Dollar Claims | This analytic reviews high dollar lab claims with at least 5 lines and a payment greater than $500 that are potentially unsupported by an order from a qualified healthcare professional. |
| Cross-coder Outpatient Facility Surgical Claims | This analytic identifies outpatient facility claims with surgical procedure codes that do not match the professional claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met. |
| Digital Spike Analysis | This analytic will target when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify the required additional time and extra work was done to support the billing of this code. |
| Upcoding of Incision and Drainage Codes | This analytic identifies claims billing incision and drainage (I&D) procedure codes that are suspected to be non-incision or lower-level incision and drainage which may have been incorrectly submitted to achieve additional reimbursement, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081. |
| Misbilling of Third Order Selective Catheter Placement | This algorithm targets codes for arterial selective catheter placement of the third order for placement above the diaphragm (36217) and below the diaphragm (36247) when claim details suggest that a first or second order arterial branch above the diaphragm or below the diaphragm was more likely the location of the procedure. Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. |
| Cross-coder Professional vs. Outpatient Facility Surgery Claims | This analytic identifies professional claims with surgical procedure codes that do not match the outpatient facility claim codes for similar services provided to the same patient on the same date of service. Records will be reviewed to ensure coding/documentation guidelines are met. |
Associated Code for EOP: EXbo
Description: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED
Editing Area | Description |
|---|---|
Critical Care Coding Requirements Unlikely to be Met | This review seeks to ensure appropriate critical care billing for illnesses or injuries. |
Upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures |
This review of professional and outpatient claims seeks to ensure that documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure. |
Associated Code for EOP: CPIMR
Description: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED
Unbundled Treatment Codes
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 2/1/2026.
Description of Changes:
Unbundled Treatment Codes: MH/SUD Providers: This correct coding edit’s goal is to look for incorrect coding based on the following scenarios:
Scenario 1: Deny claim billed with codes 80305, 80306, 80307, G0480, G0481, G0482, G0483 if another claim is already submitted/paid billing G2067, G2068, G2069, G2073, G2074, G2075, within 7 calendar days for the same pt and the same provider.
Scenario 2: Deny claim billed with codes G2067, G2068, G2069, G2073, G2074, G2075, if another claim is already submitted/paid billing codes 80305, 80306, 80307, G0480, G0481, G0482, G0483 within 7 calendar days for the same pt and the same provider.
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.
Q4 Year End Push
As we approach the final quarter of the year, we’re entering a critical phase of the Continuity of Care (CoC) program. Our shared goal remains clear: to ensure patients receive timely, high-quality care while closing the most impactful clinical gaps by December 31st. To support you in this effort, we’ve refined the appointment agenda to focus on the most urgent and actionable opportunities with a particular emphasis on risk adjustment conditions. This streamlined approach is designed to:
- Prioritize the highest-value clinical care gaps for closure
- Maximize your time during each patient encounter to focus on the more critical clinical and care items
- Ensure documentation efforts are aligned with confirmed and clinically relevant conditions
By concentrating on these key areas, we can collectively improve care quality, enhance patient outcomes, and ensure accurate risk adjustment data capture.
We appreciate your continued partnership and dedication to delivering high-quality, patient-centered care. If you have any questions or need support, please reach out to your health plan representative.
Thank you for your dedication and collaboration.
Multiple Options to Check Eligibility
As we approach year end and open enrollment, Ambetter of Tennessee provides multiple options to check member eligibility. For more details on these options and to read about grace periods, visit our Provider News Page.
Ambetter Health Solutions
Ambetter of Tennessee is rolling out a new network effective January 1, 2026. The new network will be Ambetter Health Solutions which will be under our standard Marketplace-Exchange product. The Ambetter Health Solutions network will exclusively service the Individual Contribution Health Reimbursement Arrangement (ICHRA) market, an employer-sponsored approach to access health insurance options for employees through Marketplace products.
With employer-sponsored health plans continuing to become more cost prohibitive, ICHRAs can be an option to make costs more predictable while offering more plan options for employees to choose from. ICHRAs can make coverage possible for employers that have traditionally not offered health insurance for their employees.
How an ICHRA Works:
- Employers Select a Benefits Platform—Benefits platforms act as an administrator, coordinating transactions, providing decision support to employees, and serving as a place to enroll.
- Employers Define Their Contribution—Employers set an overall budget and the pre-tax contribution for healthcare coverage.
- Employees Shop Marketplace Plans & Enroll—Employees shop plans based on their own unique needs and enroll through your chosen benefits platform.
- Employees Get Reimbursed—Employees are reimbursed for health coverage based on employer-defined contributions.
Under Ambetter Health Solutions plans, providers will be able to track these members through a unique member card. Ambetter Health Solutions members will experience the wide array of coverage and perks available to current Ambetter members such as the Ambetter Health App, Pharmacy Program, Virtual 24/7 Care, and Care Management Services.
Please Note: As a current Ambetter provider, there is nothing you need to do to be part of this network and see new Ambetter Health Solutions members after January 1, 2026.
Quality Improvement
Preparing for ECDS Reporting
The quality improvement team is pleased to share important updates regarding upcoming enhancements to the HEDIS (Healthcare Effectiveness Data and Information Set) reporting process. These changes are designed to strengthen data accuracy, improve efficiency, and reduce the administrative workload for our valued provider partners.
As part of a national transition, the National Committee for Quality Assurance (NCQA) is implementing Electronic Clinical Data Systems (ECDS) reporting. This modernized approach represents a significant evolution in the way HEDIS data is collected and analyzed. ECDS reporting emphasizes the use of digital clinical data sources—such as electronic health records, health information exchanges, and registries—instead of traditional manual chart reviews. By shifting toward digital data integration, the health plan and participating providers can achieve faster, more accurate, and more comprehensive measurement of healthcare quality. The goal of ECDS is to ensure that every patient encounter contributes directly to performance measurement without the need for redundant data collection or manual abstraction.
Currently, the health plan utilizes a hybrid reporting model for HEDIS, relying on both manual chart reviews and claims data. To align with the national movement toward data-driven, real-time quality improvement, the plan will gradually transition to Electronic Clinical Data Systems (ECDS) reporting. The transition is slated for full implementation by Measurement Year 2029, providing a phased approach that allows ample time for providers to acclimate to the system changes while upholding the accuracy and continuity of HEDIS results. Following this period, ECDS will be established as the primary method of HEDIS reporting.
A key component of this improvement involves granting the health plan read-only access to Electronic Medical Records (EMR). Secure EMR access enables our quality team to review clinical data directly from primary sources, ensuring that measures accurately reflect the care you provide. This process eliminates the need for manual record retrieval and reduces the administrative burden on your office staff. All EMR access is conducted through approved, HIPAA-compliant systems and established provider permissions, ensuring patient privacy and data security at every step.
In addition to EMR access, the health plan is expanding the use of Supplemental Data Files to improve the accuracy and efficiency of data reporting. Supplemental data allows us to capture clinical information directly from your electronic systems, minimizing the need for manual chart submissions and reducing potential discrepancies. By establishing a regular, secure exchange of supplemental data, providers can benefit from improved quality scores, more consistent performance tracking, and a streamlined reporting experience overall.
Our quality team is available to assist your practice in getting started. We will work with you to set up secure EMR access or establish automated supplemental data transfers tailored to your system’s capabilities. Our team can provide technical guidance, documentation, and testing support to ensure a smooth implementation process.
These initiatives represent our ongoing commitment to partnership, transparency, and quality improvement. Together, we can enhance patient outcomes, ensure data accuracy, and simplify the reporting process for your organization.
Risk Adjustment
Chart Chase Season
Ambetter of Tennessee is currently active in our 2025 Date of Service (DOS) Risk Adjustment Chart Chase Project, running from October 2025 through April 2026. Your participation is essential for accurate data collection and improved care outcomes. Please prioritize medical record requests from our designated vendor, Datavant. Here’s to a successful chart chase season!
Risk Adjustment Data Validation (RADV)
We’ve officially launched our annual RADV Audit Chart Chase Project, and we need your support in responding to a Department of Health & Human Services (HHS) mandated audit. HHS initiates and oversees audits of health plans, particularly those participating in Medicare Advantage (MA) and subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Tennessee is included in this audit, and full compliance is required from both our organization and our contracted providers. To ensure timely and accurate responses, please prioritize medical record requests coming from our designated vendor, Optum. Your partnership is critical to the success of this initiative. Thank you for your continued collaboration.
Continuity of Care/Continuity of Care Plus (CoC/CoC+)
Ambetter of Tennessee is committed to supporting your efforts to deliver high-quality care to our members. To further this commitment, we are launching the CoC/CoC+ program for 2025. This initiative brings together Appointment Agendas, HEDIS measures, and pharmacy metrics into one comprehensive view. The CoC/CoC+ program is designed to support your outreach efforts for annual visits, chronic condition management, and closing care gaps. It also provides insights into members identified as high utilizers or those with multiple ER visits—helping us better identify candidates for case management. For more details on the CoC/CoC+ program and the Provider Incentive Payout Bonus, please visit your provider portal or contact your health plan representative.
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.
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.
Payment Policy Updates
CC.PP.075
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 a new policy that Ambetter of Tennessee will be implementing, effective on or after 2/1/2026.
Policy Number | CC.PP.075 |
|---|---|
Policy Name | Newborn Inpatient Stays |
EX Code | EXhn (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration |
Description | Review claims for coding appropriateness when normal newborn stays with non-NICU revenue codes are billed. |
CC.PP.066 & CC.PP.076
Effective 2/1/2026 Ambetter of Tennessee will begin applying national CPT billing guidelines for the appropriate coding of physician 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 of Ambetter of Tennessee E&M Program:
- Evaluates and reviews only high-level E&M services based upon diagnostic information that appears on the claim.
- 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.
Providers should report E&M service in accordance with American Medical Association’s (AMA) CPT Manual and the Centers for Medicare and Medicaid Services (CMS') guidelines for billing E&M service codes; “Documentation Guidelines for Evaluation and Management”. The proper reporting of E&M Services enables Ambetter of Tennessee to more precisely apply reimbursement-coding guidelines and ensure that an accurate record of patient care history is maintained.
Determinations should be made with reference to accepted standards of medical practice and the medical circumstances of the individual case.
Policy Number | CC.PP.066 & CC.PP.076 |
|---|---|
Policy Name | Leveling of Care Office Based EM Overcoding & Leveling of Care Emergency Department EM Overcoding |
Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members.
Community Events
Ambetter of Tennessee is committed to supporting our community. 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.
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.