Ambetter Value & Virtual Access Referral Requirement Reminder

Fecha: 15/02/22

To create a more streamlined healthcare journey for Ambetter from Superior HealthPlan members, Ambetter created the Ambetter Value and Ambetter Virtual Access plans. As you begin to see Ambetter Value or Virtual Access members, we want to share an important reminder about billing for services:

Ambetter Value and Virtual Access Referral Requirements

These plans feature a Primary Care Provider (PCP)-centric approach to care delivery. PCPs coordinate our members’ 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 a PCP. The only exclusions from this requirement are emergency or urgent care services, as well as in-network mental or behavioral health services, and obstetrical or gynecological services.

For Primary Care Providers

As a PCP, please ensure you are submitting referrals anytime an Ambetter Value or Virtual Access member requires care beyond your scope. Referrals can easily be submitted via the secure provider portal at Provider.SuperiorHealthPlan.com.

If you have already directed a member to specialist care without submitting a referral, we ask that you submit a retroactive referral, so that the specialist services rendered are appropriately covered per the member’s benefits. Retroactive referrals are submitted in the same manner as a regular referral, you simply adjust the start date on the referral form to reflect the past date on which the referral was originally made.

For Specialists

As a specialist, please ensure your Ambetter Value and Virtual Access patients have a PCP referral anytime you provide services. Referral status can be viewed via the secure provider portal at Provider.SuperiorHealthPlan.com. Again, for services to be covered, you must have a referral from the member’s PCP.

To ensure your claims process appropriately with these referral requirements, please include the specific taxonomy that reflects your area of specialty when billing. Claims submitted with a generic taxonomy, like the following, may result in a denial if we are unable to match the provider specialty to the service.

• Taxonomy 193200000X = “Multi-Specialty”
• Taxonomy 261QM1300X = “Clinic/Center: Multi-Specialty”
• Taxonomy 193400000X = “Single Specialty”

If you have any questions about Ambetter Value or Ambetter Virtual Access plans, or making referrals, please contact Provider Services at 1-877-687-1196. We appreciate your continued partnership.