Ambetter Pre-Authorization Exemption Program: Claims Filing Reminder

Date: 04/18/25

Ambetter from Superior HealthPlan would like to remind providers that they will be exempt for six months from obtaining prior authorizations for specific services in which, during the review period, if they received 90% medical necessity approval, with a minimum of five requests per service/procedure code/prescription. The exemption occurs at the National Provider Identifier (NPI) level, not the Tax Identification Number (TIN)/Group level.

Please Note: This article is a reminder from the previously posted article: Ambetter Preauthorization Exemption Program.

Claims Filing

If you are the ordering physician for an exempted procedural/service code, and another non-exempt provider is delivering the service, the rendering physician/provider’s claim must include your name and NPI on the following claims:

• In fields 17 and 17B of the CMS Form 1500 and in fields 76-79 of the CMS Form 1450 (UB-04); or
• In the corresponding fields for electronic claims using the ASC X12N 837 format.

If the information listed above is not included on the rendering physician/provider’s claim, the claim will be subject to applicable prior authorization requirements.

DN Qualifier

To ensure timely and accurate processing, we require all providers to include the DN qualifier in their claim submissions. Please make sure to submit the DN qualifier in boxes 76 through 79 of the CMS Form 1450 (UB-04). The DN qualifier is essential for accurately identifying the exempted provider to avoid claims denials.

Please Note: TAC Preauthorization Exemption regulation, section E outlines the issuer's responsibility to provide coding guidance to physicians and providers, highlighting the importance of capturing all necessary information, including the DN qualifier, on claims.

For any questions on the Pre-Authorization Exemption program, please contact your Provider Representative. To access their information, visit the Find My Provider Representative webpage.