Ambetter of Alabama Q4 2025 Newsletter

Fecha: 16/01/26

On behalf of Ambetter of Alabama, we wish you a happy Thanksgiving! This Thanksgiving, we pause to express our deepest gratitude to all healthcare providers. Your unwavering dedication, compassion, and resilience make a profound difference every day. While others gather with loved ones, many of you are caring for patients and ensuring their well-being. We are thankful for all of our dedicated providers and all those who help care for our members. We are truly thankful for you.

2026 Billing Changes

Interim Billing
Effective January 1, 2026, Ambetter of Alabama 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.

TurningPoint Healthcare Solutions

As a reminder, Ambetter of Alabama launched a Cardiac Surgical Quality and Safety Management Program with TurningPoint effective 9/1/2025. While it is the responsibility of the rendering physician to obtain prior authorization, facility providers are encouraged to contact TurningPoint to verify the prior authorization has been complete for Ambetter of Alabama members prior to admission.
Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to Turning Point Healthcare Solutions, LLC and will be required for the following surgical procedures in both inpatient and outpatient settings:

Cardiac Surgeries & Procedures
Including all associated partial, total, and revision surgeries

TurningPoint’s Utilization Management & Precertification Contact Information:

Web Portal Intake: http://www.myturningpoint-healthcare.com
Telephonic Intake: 205-725-5200 | 855-586-8800
Facsimile Intake: 855-556-7113

For additional details including informational webinars, view our full announcement on the Ambetter of Alabama website.

Billing and Payment Updates

Unbundled Treatment Codes
Thank you for your continued partnership with Ambetter of Alabama. 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 1/1/2026.

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.

For additional CMS guidance regarding Opioid Treatment Programs, refer to the Medicare Benefit Policy Manual.

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.

Important Prior Authorization Updates Effective February 1, 2026

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Ambetter of Alabama 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.  

Enhanced Diabetes Care Silver Plan

Ambetter of Alabama is offering an Enhanced Diabetes Care Silver plan for its members for the 2026 plan year. The plan includes essential health benefits, along with added services that may help members manage ongoing health needs. While this plan offers enhanced benefits that may be especially helpful for managing conditions like diabetes, these features are available to all members enrolled in the plan.

With this plan, members pay as little as $0 for:

• Preferred insulin

• Covered medications used to treat diabetes, high blood pressure, high cholesterol, and mental health

• Select diabetic supplies, including lancets, glucometers, insulin syringes, pen needles, ketone and urine test strips

• Labs such as routine A1c tests

• Annual retinal eye exam

• Routine foot care

• Care Management to support your health goals

Service Area Expansion

We’re thrilled to announce our launch in Montgomery County, Alabama for 1/1/26! This marks an important step in expanding our reach and serving the Alabama Marketplace community with excellence. We look forward to building strong partnerships and making a positive impact in the region. Thank you to all the Montgomery area providers who helped make this possible!

Risk Adjustment

Chart Chase Season
Ambetter of Alabama 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 Alabama 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 Alabama 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.

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.

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.

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!

• We offer Alabama Provider Town Halls monthly on every 2nd Tuesday at 12 PM CT/1 PM ET.

• Please utilize all features & functions found in our Ambetter of Alabama website.

• Remember to contact your Provider Engagement Administrator with any demographic updates.

• Providers can create an account or login to our portal HERE.

• Do you have ideas for the newsletter? Please contact Amber Neal.