Reminder: Referrals Required for Ambetter Value and Virtual Access

Date: 07/14/23

As a reminder, referrals for some Ambetter from Superior HealthPlan services must be provided by a member’s assigned Primary Care Provider (PCP). 

Ambetter Health’s Value plan features a PCP-centric approach to care delivery.

• PCPs coordinate a member’s medical care, as appropriate, either by providing treatment or by issuing referrals to other in-network providers.
• For services to be covered, they must be provided by or referred by the assigned PCP group.

Ambetter Health’s Virtual Access plan provides an option to members seeking a quality-focused, virtual approach to their healthcare.

• This plan provides adult members (ages 18 and older) with unlimited virtual primary care services for both medical and behavioral health benefits.
• Members under the age of 18 will be assigned to a local PCP.
• PCPs help navigate care needs by providing appropriate referrals to other in-network providers for any other non-virtual care services that are needed.

Both, Value and Virtual Access plans allow for access to the following services without a referral:

• Emergency or urgent care services
• In-network mental or behavioral health services
• Obstetrical or gynecological services
• Labs, radiology, durable medical equipment, ambulance and anesthesia services

Referrals and claims must be submitted through Superior’s Secure Provider Portal. Please note:

• When submitting claims for referred services, providers must include the reference number from the secure provider portal in box 23 of the claim.
• If a reference number is not submitted, the claim will be denied.

Providers are encouraged to attend the monthly Ambetter from Superior HealthPlan webinar for additional information. For a complete list of upcoming trainings, please visit Superior’s Provider Training Calendar webpage.

For additional questions, please contact your local Account Manager.