Q2 2025 Provider Newsletter

Fecha: 15/07/25

Ambetter of Alabama Wins Most Outstanding Sponsor

We are thrilled to share that Ambetter of Alabama has been honored with the Most Outstanding Sponsor Award at The Women's Expo HSV in Huntsville, Alabama! The Award was presented by Founder & Visionary of the Women's Expo, Tiffany Draper.

Trillo M. Shipman (Director of Community Relations AL/TN) and LaToi Currie (Ambetter Health's Community Relations Program Manager II) attended the 3-Day event. On behalf of Ambetter of Alabama, Trillo M. Shipman proudly accepted the award.

This incredible recognition comes from an event that truly celebrates the power and potential of women. The Women's Expo HSV is much more than just an event—it's a vibrant, empowering space designed to bring women together from all walks of life. It's where connections are made, stories are shared, and inspiration flows freely.

In celebration of Women's History Month, the Expo creates an uplifting atmosphere filled with dynamic workshops, thought-provoking talks, and engaging panel discussions. Topics range from finding balance in our busy lives and developing strong leadership skills, to becoming more financially empowered and nurturing personal and professional growth.

Ambetter of Alabama is proud to have played a role in supporting this meaningful experience. We believe in championing the health and well-being of our communities, and we're honored to stand alongside so many amazing women who are making a difference every single day.

To all who attended, presented, and shared their stories—thank you for creating a space where women can uplift and empower each other. Here's to continuing the momentum and building even stronger communities together.

Cardiac Surgical Quality and Management Program through TurningPoint

Ambetter of Alabama has contracted with TurningPoint to provide an innovative solution to work collaboratively with providers, facilities, and physicians to reduce treatment variability, promote safety, quality of care improvements, and support for your patients. TurningPoint Healthcare Solutions, LLC (TurningPoint) provides an innovative Cardiac Surgical Quality and Management Program which empowers the collaboration of patients, payers, and providers to improve the quality and affordability of healthcare services. This partnership goes live 9/1/2025.

As part of this program, Ambetter of Alabama has delegated its utilization management function to TurningPoint for a limited scope of procedures, which are listed below.

• Coronary Angioplasty/Stenting
• Implantable Cardioverter Defibrillator
• ICD Revision or Removal
• Pacemaker
• Pacemaker Revision or Removal
• Peripheral Revascularization
• Percutaneous Transcatheter Closure
• Coronary Artery Bypass Grafting
• Internal Cardiac Monitoring
• Leadless Pacemaker
• Left Atrial Appendage (LAA) Occludes
• Non-Coronary Angioplasty/Stenting
• Valve Replacement
• Cardiac Ablation
• WCD – Wearable Cardiac Defibrillator

Prior Authorization is required for inpatient, outpatient, and doctor’s office settings for these procedures. The preferred method to initiate a prior authorization request is through TurningPoint’s provider portal at https://myturningpoint-healthcare.com. When necessary, providers may also submit requests by fax (855) 556-7113 or by phone (855) 586-8800 (Toll-Free).

For questions regarding the TurningPoint Program, or to setup an in-service with your practice, please call (866) 422-0800.

Elective Medical Inpatient Authorization Process Change

To provide increased flexibility and better align with industry best practices, we are making 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.

Availity Editing Services

In a continuous effort to make it easier to do business with us, Ambetter of Alabama 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 AmbetterAL_ProviderRelations@centene.com.

Risk Adjustment

Risk Adjustment (Continuity of Care/CoC)

Ambetter of Alabama 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 launched 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)

This month we 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 DHHS initiates audits of health plans subject to risk adjustment under the Affordable Care Act (ACA). Ambetter of Alabama 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.

Skin and Soft Tissue Substitute Policy and Prior Authorization Updates

Ambetter of Alabama is notifying providers of an update to the policy regarding prior authorizations of Skin and Soft Tissue Substitutes for Ambetter Health members.

Effective July 1, 2025, Clinical Policy: Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) will require all codes listed within to be reviewed for prior authorization. This policy outlines the review process and clinical rationale for using various types of substitutes available within the healthcare services market.

For the complete Skin and Soft Tissue Substitute Policy, please visit Ambetter Health’s Clinical policy page.

All policies and procedures are regularly reviewed as part of our commitment to delivering quality, cost-effective care for Ambetter Health members. Please contact your health plans provider engagement team for additional information and questions related to this policy update.

Thank you for your partnership and commitment to improving the health of our communities, one person at a time.

Additional Codes Needing Prior Authorization

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

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 (eg, balloon dilation); frontal and sphenoid sinus ostia

31295 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa

31296 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

REMINDERS

Thank you for being a valued partner in our provider network!

If you receive a survey from us, please provide honest feedback regarding your experience with us. Sharing your experience in this brief survey is how you can help us gain valuable insights to enhance and improve provider tools, resources, and operations to better support you.
We look forward to receiving your valuable feedback. Thank you!

• Please utilize all features & functions found in our Ambetter of Alabama website.
• Beginning January 1, 2025, the Bronze I Silver I Gold network was renamed to the PREMIER network. Members were notified through various notifications and will see this change in the Ambetter Guide.
• Remember to contact your Provider Engagement Administrator with any demographic updates.
• Providers can create an account or login to our portal HERE.
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