Q1 2025 Provider Newsletter

Fecha: 18/03/25

Network Highlights

Ambetter of Alabama is expanding its network to provide better access for our members. Our goal is to offer providers the opportunity to meet members anywhere. Please review our in-network providers below.

In-Network Providers

• Andalusia Health
• Ascension Sacred Heart Hospital Pensacola
• Baptist Montgomery - New provider
• Bullock County Hospital
• Choctaw General Hospital
• Community Health Systems (CHS)
• Crestwood Medical Center
• Cullman Regional Medical Center
• Flowers Hospital
• Gadsden Regional Medical Center
• Grandview Medical Center
• Huntsville Hospital System
• Infirmary Health System - New provider
• LifePoint Health
• Medical Center Barbour
• North Alabama Medical Center
• Orlando Health
• Piedmont Columbus Regional-Midtown Campus
• Piedmont Columbus Regional-Northside
• Regional Medical Center (RMC)
• South Baldwin Regional Medical Center 
• Southeast Health- New provider
• Springhill Medical Center
• St. Francis Hospital
• St. Vincent - New provider
• University of Alabama Birmingham Health System - New provider
• University of South Alabama Children’s & Women’s Hospital
• USA Children and Women’s Hospital
• USA Health University Hospital
• Vaughan Regional Medical Center

For a complete list of Ambetter Health in-network providers, please visit guide.ambetterhealth.com. Availability varies by product/county.

Provider Resources

Ambetter of Alabama Monthly Provider Orientation and Office Hours via Teams (every 3rd Wednesday of each month at 10am Central Time) Next Scheduled Meeting: 3/19/25 - Join the meeting now

As a reminder the 2025 Provider Manual (PDF) is ready! You can find a variety of resources on this page including the Quality and Risk Adjustment resources, and various provider education. Please use our reference guide (PDF) for step-by-step instruction for changes.

Have you had recent changes to your practice such as new providers, new locations, or similar? We are glad to help you with making those changes effective to prevent delays in processing claims. This will also ensure your practice displays correctly in our directory. Our Provider Data Management team supports our providers by assisting with the following:

• Demographic Updates and Changes
• Adding Providers to existing Groups or Practices
• Provider Termination Requests

Please submit updates within 30 days of data change becoming effective to our Provider Data Management team by emailing your request to the email address below. You can also use our roster form if you have a large number of updates. Email us at: sm_ambetteralops@centene.com

Quality Updates

HEDIS season has started!

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 has started and will continue 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)
• Glycemic Status Assessment for Patients with Diabetes (GSD)
• Cervical Cancer Screening (CCS)
• Immunizations for Adolescents (IMA)
• Childhood Immunization Status (CIS)
• Eye Exam for Patients with Diabetes (EED)
• Prenatal and Postpartum Care (PPC)
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

As more measures require Electronic Clinical Data Systems (ECDS) Reporting, we would like to collaborate with providers in our network. EMR Connectivity/Integration/SUDS Supplemental Data - Your partnership in Direct Remote EMR Access and/or Bi-Directional Feed is a great way to close care gaps, improve quality of care, and aims to reduce administrative burden. There are significant benefits of remote access to patient charts, improving accuracy, completeness of patient data, and enhanced patient care. For more information or to get started, please review the SUDS document (PDF). Our goal is to ensure a seamless and efficient process throughout the season.

CAHPS:

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a survey tool that asks members to evaluate their experience with their health plan and providers’ offices. CAHPS is an annual survey administered to an anonymous, random sample of members (February/March – June). For Ambetter, it is known as the Qualified Health Plan Enrollee Experience (QHP EE) survey. The survey is used to evaluate consumer experiences and how members perceive key aspects of the care they received in the last six months. CAHPS participation is a CMS requirement for Medicare Star Ratings and Marketplace Quality Rating System (QRS). It is also a National Committee for Quality Assurance (NCQA) requirement for health plan accreditation and Health Plan Rating System (HPR). Each of these rating systems are publicly reported. The following are the provider-influenced measures and their weight.

Our commitment to delivering outstanding patient experiences starts with you. Your dedication is central, and we want to ensure you feel valued by knowing how your patients view your care. Please encourage your patients to complete the survey when received. We value their feedback.

Claims & Appeals Timeframe

Ambetter of Alabama is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary upfront rejections or denials.

Please reference our 2025 Provider Manual (PDF) for more information.

Timely Filing

Initial Claims Calendar Days

• Par - 180 days
• Non-Par - 180 days

Reconsideration or Claim Dispute/Appeals 

• Par - 180 days
• Non-Par - 90 days

Coordination of Benefits 

• Par - 180 days from the primary payers EOP Date to the date received 
• Non-Par - 90 days from the primary payers EOP Date to the date received 

Routine Foot Care

Ambetter Health reimburses for routine foot care in accordance with state mandates and CMS guidelines. Routine Foot Care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty. Based on CMS guide for routine foot care modifiers Q7, Q8 and Q9 are being added to further ensure Ambetter Health benefit(s) are applying routine foot care cost share for routine foot care services.

All other services will apply Surgical/Specialist/Doctor/Facility cost share depending on provider billing. 

Effective 1/1/2025 routine foot care benefit(s) will be updated to align with the CMS guidance provided in Article - Billing and Coding: Routine Foot Care (A57957) (cms.gov).

Prior authorization may be required. Please reference the Provider Resource page.

Risk Adjustment

Risk Adjustment - Chart Chase Season

Ambetter of Alabama is currently active for our 2024 DOS Risk Adjustment Chart Chase project. The project runs from October 2024 through April 2025. 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 be coming from the vendor: Datavant. Here's to a successful chart chase season!

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.

Clinical & Pharmacy Policies

Ambetter of Alabama 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. Please refer to the Clinical & Payment Policies page for a list of clinical policies and reach out to your Provider Relations representative if you have any questions.

In a continuous effort to make it easier to do business with us, Ambetter of Alabama has added pharmacy policies to their Clinical & Payment Policies page. Please refer to this page for pharmacy policy updates and review the revision log within each policy to view any policy changes.

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.