This document is an Individual Member Evidence of Coverage (EPO) contract from Ambetter Health Solutions that explains covered services, member rights/responsibilities, access to care, prior authorization requirements, and administrative provisions for enrolled members.
Policy Summary
PayerCentene
PolicyIndividual Member EPO Evidence of Coverage
Policy CodePolicy AMB24-GA-C-00014
Change TypeNo material change
Effective Date
Next Review Date
Key ActionObtain required prior authorization before providing services that the Schedule of Benefits indicates require it to avoid reduced benefits.
No material clinical or coverage changes in this revision.
Nov 1–Jan 15open enrollment
30 daysPCP change effective
requiredprior auth — non-emergency air ambulance
31 daysnewborn auto coverage
48 hoursemergency admission notice
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Coverage Criteria and Benefits
Coverage Overview and Requirements
Coverage is governed by the Evidence of Coverage contract and the Schedule of Benefits. Benefits are subject to definitions, provisions, limitations, exclusions, and prior authorization requirements.
Benefits provided per this contract and the Schedule of Benefits; subject to contract definitions, provisions, limitations, and exclusions.
Certain services require prior authorization; benefits may be reduced or not covered if prior authorization requirements are not met.
Members must use contracted network providers to obtain benefits except where this contract specifically allows non-network coverage (e.g., balance billing protections, directory inaccuracies, or authorized out-of-area care).
Provider directory inquiries will be answered within 1 business day; members may request a printed directory at no charge.
Adverse benefit determinations, internal appeals, and external review rights are available as described in the Appeals, Grievances and External Review Procedures section.
Coverage criteria and member obligations
Coverage stance and member responsibilities for network vs non-network services, emergency services, and balance billing protections.
Emergency services to evaluate and stabilize an emergency condition are covered without prior authorization; facility, physician charges and related drugs are included; if admitted, member or physician must notify Us within 48 hours or as soon as reasonably possible.
Balance billing protections under the No Surprises Act apply for emergency services, air ambulance services, and certain non-emergency services at network facilities; a notice-and-consent process (with strict timing and documentation rules) is required to waive protections for scheduled non-network services.
When services are received from network providers, the allowed amount is the contracted fee. For non-network providers the eligible expense and member liability are determined per this contract and applicable law; members may be balance billed for amounts above the allowed amount unless balance billing protections apply.
Services determined to be not medically necessary, experimental/investigational, or custodial are excluded from eligible expenses; such determinations may be appealed using internal and external review processes.
Eligibility and enrollment coverage criteria
Member eligibility and coverage continuation rules
Automatic newborn coverage: an eligible child born to a covered member is covered from time of birth until the 31st day after birth; to continue coverage beyond 31 days additional premium and notification are required per the contract.
Adopted child coverage: an eligible child legally placed for adoption is covered from date of placement until the 31st day after placement; continuation beyond 31 days requires notification to Georgia Access within 60 days and payment of any required premium within 90 days.
Dependent termination: dependent coverage ceases at the end of the premium period in which the individual ceases to be an eligible dependent; eligible children’s coverage terminates at the end of the calendar year in which they turn 26 except when disability exceptions apply.
If a member is inpatient on the contract effective date and prior coverage continues to cover hospitalization after its termination, Ambetter will not cover those services until discharge or exhaustion of prior coverage; member must notify Ambetter within 2 calendar days of effective date for review/authorization.
Enrollment Criteria and Effective Dates
Enrollment and special enrollment criteria and effective dates
Open enrollment: initial open enrollment period runs November 1, 2024 through January 15, 2025; individuals who enroll on or before December 15, 2024 will have an effective date of January 1, 2025.
Special enrollment triggers include loss of minimum essential coverage, marriage, birth, adoption, placement for adoption, foster placement, permanent move, plan violation or error, domestic abuse, and other events listed in the contract; general reporting period is 60 days (90 days for loss of Medicaid/CHIP).
Special effective dates
Regular SEP effective date is the first of the month following plan selection.
For birth, adoption or foster placement, coverage is effective on the date of the event.
Premiums and Third-Party Payments
Premium payment and third-party payment rules
Premiums are due on or before their due date; the initial premium must be paid prior to the coverage effective date (extensions may be provided during Open Enrollment).
There is a 60-day grace period for monthly premiums; during the grace period the contract remains in force but claims may pend and providers will be notified of potential denials.
Acceptable third-party payers are limited (e.g., Ryan White HIV/AIDS Program, Indian tribes/organizations, state/federal programs, family members, employers for ICHRA, certain private not-for-profit foundations); third-party payments for deductibles or cost sharing may not count toward member deductible or out-of-pocket limits.
Health Savings Account (HSA)
HSA responsibilities and applicability
Members enrolled in HSA-eligible plans must meet federal HSA eligibility to contribute; Ambetter/Peach State are not HSA trustees or custodians and do not provide tax or legal advice; members are responsible for compliance and notifying their HSA custodian if coverage is canceled or terminated.
Cost Sharing and Network Billing
Cost sharing, limits, and non-network billing
Coinsurance is the member's share of the cost of a service; coinsurance applies toward maximum out-of-pocket but not toward the deductible.
Copayments are fixed dollar amounts due at the time of service; copayments apply toward maximum out-of-pocket but not toward the deductible.
Deductible is the amount of covered expenses a member must pay before benefits apply; copayments and coinsurance generally do not count toward the deductible unless specified in the Schedule of Benefits.
Maximum out-of-pocket: member pays applicable copayments, coinsurance and deductible until reaching the individual maximum shown in the Schedule of Benefits; after the individual OOP is met the plan pays 100%. Family OOP equals two times the individual OOP and can be met by combining members' eligible expenses.
Non-network providers may balance bill members for amounts above plan payments and such amounts may not count toward annual OOP; balance billing protections under federal law prohibit balance billing in certain circumstances (see contract).
Coverage criteria and limitations
Coverage stance and specific benefit rules described in this section include major medical benefits, acquired brain injury services, acupuncture, and air ambulance services with stated limitations and exclusions.
Major medical/essential health benefits are covered when medically necessary and not experimental; EHB categories are provided and are not subject to lifetime or annual dollar maximums.
Acquired brain injury: medically necessary services (cognitive rehabilitation, neurobehavioral testing/treatment, community reintegration/post-acute services, etc.) are covered when related to the injury; custodial and long-term nursing care are excluded.
Acupuncture outpatient services are covered when provided by a network provider; see Schedule of Benefits for limits and cost sharing.
Air ambulance: emergency air ambulance to nearest appropriate facility or neonatal special care unit is covered without prior authorization; non-emergency air ambulance requires prior authorization and specific exclusions apply (e.g., outside U.S., comfort/convenience transport).
Ambulance Transport Coverage
Ambulance transport coverage and limits
Emergency ambulance transport (air, ground, water) to the nearest appropriate facility is covered; prior authorization is not required for emergency ambulance transports.
Non-emergency ambulance transport (air and ground) requires prior authorization and is excluded unless authorized; limits and exclusions apply (e.g., services outside U.S., comfort/convenience transport).
Transfers between facilities (including movement from non-network to network when directed) are covered when authorized by the plan.
DME and Medical Supplies
Durable medical equipment and supplies coverage
DME: rental or purchase of durable medical equipment prescribed by a provider is covered when medically necessary; examples include wheelchairs, crutches, hospital beds, oxygen equipment; repair, adjustment and replacement are covered under conditions.
DME limits and exclusions: reimbursement limited when item includes non-medically necessary comfort/luxury features; replacements for lost or stolen items and repairs due to misuse are excluded; reasonable quantity limits may apply and some items require prior authorization.
Non-durable medical supplies with a primary medical purpose are covered subject to quantity limits and cost sharing; common home items (e.g., Band-Aids) and certain non-covered supplies are excluded.
Autism Spectrum Disorder Coverage
Autism Spectrum Disorder services
Coverage for ASD includes evaluation and assessment, applied behavior analysis (ABA), speech, occupational and physical therapy, psychiatric care, medications and nutritional supplements when prescribed; ABA has no stated numeric limit but is subject to prior authorization to determine medical necessity.
Prosthetics
Prosthetics coverage and exclusions
Prosthetic devices that replace missing body parts are covered, including purchase, fitting, adjustments, repairs and replacements when medically necessary; applicable taxes and shipping are covered; certain specific devices (LVAD as bridge to transplant, internal valves, hearing devices, intraocular lenses, ostomy supplies, wigs in specified circumstances) are listed as covered.
Exclusions: dental appliances, dentures, non-rigid appliances (elastic stockings, arch supports) unless integral to brace, wigs except as specified, and penile prostheses when medical necessity criteria not met or cosmetic.
Preference for purchase over rental when medically appropriate; prosthetic maximums, if any, do not apply for certain mandated items (e.g., breast prosthesis after mastectomy per WHCRA).
Diabetes, Dialysis, and Clinical Trials
Additional clinical and chronic care services
Diabetes care: coverage for exams, routine foot care, laboratory testing, prescribed glucose monitors and supplies, orthotics and diabetic shoes, education and self-management training when provided by certified professionals.
Dialysis: acute and chronic dialysis services are covered when medically necessary in facility or home settings; equipment and supplies for home dialysis covered with purchase/rental determinations and prior authorization where applicable.
Clinical trials: routine patient care costs for qualifying clinical trials (phases I-IV) are covered when trial and site meet specified accreditation/funding criteria; investigational items solely for data collection and sponsor-provided items may be excluded unless otherwise covered.
Care Management
Care management
Care management: care managers (registered nurses or social workers) coordinate services, locate community resources, and develop care plans for members with complex needs; members may enroll by calling Member Services.
Prosthetics and exclusions
Prosthetic devices and related supplies
Covered prosthetic aids and supports include internal heart valves, pacemakers, breast prosthesis post-mastectomy (with four surgical bras per benefit period), intraocular lenses, colostomy supplies, hearing aids/cochlear implants, restoration prosthesis, and wigs when purchased through a network provider (one per benefit period).
Orthotics
Orthotic devices coverage and replacement frequency
Orthotics: initial purchase and repair of custom rigid or semi-rigid orthotic devices are covered, including casting, molding, fittings and adjustments; applicable taxes and shipping covered. Orthotics may be replaced once per year when medically necessary; additional replacements allowed for rapid growth or irreparable damage.
Exclusions: foot support devices such as arch supports are excluded unless integral to a leg brace; non-specialty items (garter belts, etc.) are excluded.
Emergency Services
Emergency care access and stabilization provisions
Emergency services are covered 24/7 both in and out of the service area; non-network emergency providers are subject to balance billing protections and may not balance-bill members for amounts beyond the allowed amount.
Family Planning
Family planning and contraceptive preventive care rules
Full range of FDA-identified contraceptives and related services (screening, education, counseling, provision, follow-up, and services integral to provision) are covered as preventive care without member cost share when provided by a network provider and lawful.
Rehabilitation and LTACH
Rehabilitation and LTACH criteria
Rehabilitation services and confinement in a rehabilitation or extended care facility are covered when medically necessary; facility and professional service limits apply and benefits cease when rehabilitation endpoints are met.
LTACH services: covered for clinically complex patients meeting specified criteria (complex wound care, infectious disease, medical complexity, rehabilitation needs, mechanical ventilation criteria) and are subject to prior authorization.
Home Health Care
Home health coverage, visit counting, and limits
Home health care is covered when physician determines member cannot travel to provider office; includes home health aide services, licensed therapist professional fees, hemodialysis, IV meds and medically necessary supplies; services are subject to prior authorization.
Visit counting: each 8-hour period of home health aide services counts as one visit; respite, custodial and educational care are excluded under Home Health benefits.
Hospice
Hospice care coverage and conditions
Hospice benefits for terminally ill members include room and board (limited to most common semiprivate room rate), therapies, rental of medical equipment, palliative/supportive care, counseling, and bereavement services; benefits are subject to prior authorization and certain exclusions (e.g., respite) apply.
Hospital Benefits
Hospital inpatient and outpatient service coverage
Hospital benefits: daily room and board and nursing services up to the hospital's most common semiprivate room rate, ICU room and board, operating/recovery room use for outpatient and inpatient surgery, routine inpatient drugs and supplies, and private room when isolation is required; refer to Schedule of Benefits for limits.
Infertility
Infertility treatment coverage and limitations
Infertility treatment is limited to medically necessary services for diagnosis of infertility; treatments such as artificial insemination, IVF, surgical conception procedures and related drugs are excluded.
Maternity & Newborn
Maternity stays, newborn coverage and federal minimum stay protections
Maternity: inpatient stay minimums of 48 hours after vaginal delivery and 96 hours after cesarean are covered; certain maternity services may require prior authorization but delivery itself does not require prior authorization for the provider to perform delivery.
Newborns: medically necessary hospital services for a covered newborn are provided immediately after birth; newborns have separate cost-sharing per the Schedule of Benefits and automatic coverage for 31 days with conditions to continue beyond that period.
Coverage criteria and limits
Miscellaneous covered services including behavioral health, dental anesthesia, medical foods and outpatient medical supplies with limits
Medical/surgical services: surgery, pre/post-surgical testing, lab, imaging, biomarker and genetic testing, chemotherapy, radiation, infusion therapy, DME, prosthetics, and reconstructive surgery after mastectomy are covered when medically necessary and per contract terms.
Behavioral health and SUD: a broad set of inpatient and outpatient services are covered in parity with medical/surgical benefits; some services may require prior authorization but emergent inpatient withdrawal management and emergent inpatient treatment do not require prior authorization.
Dental/anesthesia: anesthesia and hospital charges for dental care are covered for members under 19 or those with disabling conditions when hospitalization is required; general anesthesia in hospital/ASC may require prior authorization.
Medical foods and low-protein products: outpatient enteral therapy, outpatient TPN, elemental formulas, low-protein food products for specified inherited metabolic diseases, and up to two months of pasteurized donor human milk when prescribed are covered.
Outpatient, vision and pharmacy coverage criteria
Outpatient, vision and pharmacy coverage rules including day supply limits and restrictions
Outpatient behavioral health services (IOP, PHP, individual/group therapy, medication assisted treatment, medication management, detox, rehabilitation, ABA, ECT, TMS, day treatment, telehealth) are covered when medically necessary; some services may require prior authorization, but emergent inpatient withdrawal and emergent inpatient treatment are exempt.
Outpatient medical supplies: prosthetics, orthotics, CPM machines, respiratory and cardiac rehab, infusion therapy, and certain eye-related supplies are covered with specified limits; prosthetic coverage is at least 80% of Medicare allowable.
Pediatric vision benefits for members under 19 include routine exams, refraction, frames and lenses with multiple lens options; refer to Schedule of Benefits for cost sharing and limits.
Prescription drugs: covered when prescribed and dispensed by a licensed pharmacy; formulary guides coverage and tiers; oral anticancer meds covered no less favorably than IV/injectable cancer meds.
Exceptions and prior authorization
Exception request handling, prior authorization requirements and external review timelines
Exception requests for non-formulary drugs: standard and expedited exception requests are available; expedited decisions are made within 24 hours and standard external review determinations within 72 hours (24 hours if original was expedited).
External exception review: if external review granted, coverage provided for duration of prescription or exigency per the determination timelines.
Prior authorization: certain services (e.g., radiology/imaging, sleep studies, transplants, DME, home health, LTACH) require prior authorization as specified in the Schedule of Benefits and provider authorization procedures; transplant authorization must be obtained through the Center of Excellence prior to evaluation and related services.
Preventive services
Preventive services coverage per ACA
Preventive care items and services recommended by USPSTF (A/B), ACIP immunizations, and HRSA guidelines are covered without member cost share when provided by a network provider; diagnostic services billed as diagnostic are not treated as preventive and appropriate cost sharing applies.
Breast cancer screening: preventive mammograms, ultrasounds and MRIs are covered with the same preventive cost sharing; diagnostic breast imaging also treated equivalently for cost sharing rules.
Transplant coverage: transplants are covered when member is accepted as a transplant candidate and preauthorized; prior authorization through the Center of Excellence is required before evaluation and related services; covered items include pre-transplant evaluation, harvesting, LVAD as bridge to transplant, the transplant itself and post-transplant follow-up when authorized.
Ancillary travel reimbursement: when member required to travel more than 60 miles to a Center of Excellence, plan will reimburse transportation, lodging and related approved expenses up to a maximum of $10,000 per transplant service with receipts and mileage logs required and reimbursement requests submitted within six months.
Transplant exclusions: prophylactic harvest without transplant, animal-to-human transplants, procurement/transport unless via Center of Excellence, unauthorized transplants, services performed outside U.S., and numerous non-reimbursable ancillary items (alcohol, tobacco, vehicle rental unless pre-approved, parking unless pre-approved, lodging when staying with friend/relative, loss of wages, personal items, upgrades) are excluded.
Second medical opinion
Second opinion availability and process
Members are entitled to a second medical opinion for minor surgical procedures, serious injury or illness, or when not responding to treatment; member may select a physician of choice (network choice minimizes cost share); second opinions from non-network providers require prior authorization and non-network providers may balance bill members unless authorization obtained and they accept network rates.
Urgent care and wellness offerings
Urgent care and wellness program references
Urgent care: medically necessary services by network providers and at network urgent care centers are covered; members are encouraged to contact their PCP first; 24/7 Nurse Advice Line is available.
Wellness programs: optional programs (My Health Pays, Ambetter Health Perks) are available at no additional cost while coverage is active; programs are vendor-administered and may offer rewards or financial tools but are not endorsements by the plan.
Non-covered services and payment conditions
General exclusions and conditions for payment
General exclusions: services not identified as covered, services provided prior to effective date or after termination, services by immediate family members, non-medically necessary services, and other specified exclusions are not covered. Services must be medically necessary, ordered by a provider, and covered under contract to qualify for payment.
Coverage exclusions and operational criteria
Selected general non-covered services and operational rules
Services or supplies provided prior to the effective date or after termination are excluded.
Experimental, investigational or unproven treatments are excluded even if no alternative treatment exists.
Weight modification programs and surgical treatment of obesity are excluded except as specifically covered elsewhere in the contract.
Cosmetic treatments are excluded except reconstructive surgery incidental to covered injury or to correct a birth defect; certain gender dysphoria-related procedures may be covered when medically necessary per contract.
Dental and routine vision services are excluded except where expressly provided under medical or pediatric vision benefits; services by family members and private duty nursing are excluded.
Claims and Coverage Criteria
Continuation of coverage for former dependent members and related claims handling
Members or former dependents must notify the insurer within 31 calendar days of legal divorce or dependent's marriage to request continuation coverage; insurer will issue continuation no less than 30 calendar days prior to a member's 26th birthday or within 30 days after timely notice of divorce or dependent marriage.
Former dependent must pay required premium within 31 calendar days following insurer notice or the new contract will be void; insurer retains subrogation and reimbursement rights to the extent third-party payments cover a loss and may require cooperation in pursuing recovery.
Claim notice/proof timing: notice of claim within 30 days and proof of loss within 90 days (or as soon as reasonably possible); foreign emergency claims have specific submission rules and coverage up to 90 consecutive days when traveling outside U.S.
Timeframes for payment: benefits processed within 30 calendar days for non-GA balance-billing claims after proper proof; GA balance-billing clean electronic claims paid within 15 working days and clean paper claims within 30 calendar days.
Appeals, Grievances and External Review Criteria
Procedures and timelines for appeals, grievances and external review
Filing window: members have 180 calendar days to file an internal appeal from the date the adverse benefit determination is issued.
Acknowledgment: the plan will acknowledge receipt and notify of needed information within 5 business days; appellant may present additional evidence and receive copies of information free of charge.
Resolution timeframes: pre-service appeals resolved within 30 calendar days, post-service within 60 calendar days, expedited appeals within 72 hours; external review decisions within 45 calendar days (72 hours for expedited external review).
Extensions: plan may extend decision time by up to 14 calendar days if additional information is needed and will notify the appellant; expedited appeals have waived standard panel/acknowledgment rules and are decided within 72 hours.
External review process: IRO assigned on rotating basis; plan must provide documents within five business days (or expeditiously for expedited); IRO decision within 45 calendar days (72 hours expedited); if IRO reverses, plan will approve the covered service.
Member contractual obligations and rights
Member contractual obligations, rights, and operational provisions
Repayment for fraud: during the first two years of coverage the plan may demand repayment of benefits if a member committed fraud, misrepresentation or knowingly provided false eligibility or claims information.
Preconditions to litigation: members must provide written notice identifying the dispute, reference contract provisions and supporting facts prior to initiating legal action; if issues are resolved within 30 days after notice, certain extracontractual damages may be waived unless prohibited by law.
PHI protection and language/auxiliary services: plan protects PHI per HIPAA and provides free language assistance and auxiliary aids at no cost; Member Services contact numbers and web resources are provided.
Members must cooperate with insurer requests for medical or other information; failure to cooperate may result in claim closure or denial.
Coding, Thresholds, and Key Numeric Rules
Rehabilitation intensity definitionsmixed
Acute rehabilitation: rehabilitation services must be performed three or more hours per day, five to seven days per week while the member is confined as an inpatient in a hospital, rehabilitation facility, or extended care facility.
Inventory placeholder (neutral)mixed
No specific billing codes listed for this inventory item.
Essential Health Benefits (EHB)mixed
Essential health benefits categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; pediatric services, including oral and vision care. These EHBs are not subject to lifetime or annual dollar maximums.
Ambulance servicesmixed
Air ambulance: covered to nearest appropriate hospital or neonatal special care unit; emergency air ambulance does not require prior authorization; non-emergency air ambulance requires prior authorization. Ground/water ambulance: emergency transport to nearest appropriate hospital covered; non-emergency ambulance transport requires prior authorization; transfers between facilities covered when authorized by the plan.
Prosthetics and Orthoticsmixed
Prosthetics: includes devices replacing all or part of missing body parts (artificial limbs, eyes), LVAD when used as bridge to transplant, internal heart valves, pacemakers, intraocular lenses, breast prosthesis and four surgical bras per benefit period, cochlear implants, hearing aids, restoration prosthesis, wigs (one per benefit period) when purchased through a network provider; repairs and replacements covered when medically necessary.
Orthotics: initial purchase and repair of custom rigid or semi-rigid orthotic devices covered; casting, molding, fittings, adjustments, taxes/shipping covered; orthotics may be replaced once per year when medically necessary (additional replacements for growth or irreparable damage).
LTACH ventilator criteriamixed
Mechanical ventilator support criterion: patient has received mechanical ventilation for 21 consecutive days for 6 hours or more per day; ventilator management required at least every 4 hours; patient exhibits weaning potential; other clinical stability criteria apply (hemodynamically stable, PEEP ≤10 cm H2O, FiO2 ≤60% with O2 saturation ≥90%).
Outpatient medical supplies/prosthetics (neutral)HCPCS
HCPCS
Outpatient medical supplies and prosthetic device coverage references HCPCS/Medicare allowable; eligible charges covered at no less than 80% of Medicare allowable.
Outpatient medical supplies / prosthetics (covered)mixedCovered
Covered outpatient medical supplies include artificial eyes or larynx, breast prosthesis, basic artificial limbs, one pair of foot orthotics per year, four mastectomy bras per year, rental of medically necessary DME, one CPM machine following covered joint surgery, infusion therapy, respiratory therapy and cardiac rehabilitation. Coverage provided for eligible charges shall be no less than eighty percent of Medicare allowable as defined by CMS (HCPCS referenced).
Services that may require prior authorizationmixed
Medically necessary radiology/imaging, sleep studies, and other diagnostic testing may require prior authorization (see Schedule of Benefits); sleep studies covered when medically necessary and may require prior authorization.
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No specific billing codes listed for this inventory item.
Foreign Emergency Claims Requirementsmixed
Emergency services while traveling outside the U.S. covered up to 90 consecutive days. Foreign claims for emergency care must be submitted in English or with English translation within 180 calendar days, include applicable medical records, use the Member Reimbursement Medical Claim Form, and reimbursement will be based on member's benefit plan, eligibility, member cost share, and the currency exchange rate at time of transaction.
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No specific billing codes listed for this inventory item.
This contract contains prior authorization requirements. Benefits may be reduced or not covered if the requirements are not met. Please refer to the Schedule of Benefits and the Prior Authorization section for details.
Billing Rule
Emergency admission notification
If a member is admitted to a hospital as a result of an emergency condition, the provider or the member must notify Ambetter (or verify that the member's physician has notified Ambetter) within 48 hours or as soon as reasonably possible. When contacted, Ambetter will notify whether the inpatient setting and the number of days are medically necessary. Care provided once the member is stabilized is no longer considered emergency services; continuation of care beyond stabilization will not be covered unless Ambetter authorizes it and it is medically necessary.
Definitions and Terms
inv-84: Acquired brain injury — definition
DefinitionAcquired brain injury: a neurological insult to the brain that is not hereditary, congenital or degenerative and occurs after birth resulting in impaired physical functioning, sensory processing, cognition or psychosocial behavior.
ScopeIncludes changes in neuronal activity leading to functional impairments
Related servicesCoverage for cognitive rehabilitation and related medically necessary services when injury-related
inv-85: Acute rehabilitation — definition including intensity thresholds
DefinitionAcute rehabilitation: intensive, multidisciplinary inpatient rehabilitation where therapies total three or more hours per day, five to seven days per week.
TherapiesCombination of physical, occupational and speech therapy as needed
Numeric Thresholds and Key Values
31 daysminimum notice for certain plan changes
90 daysdiscontinuance notice if offering stopped statewide
10 daysright to return contract (full refund less claims)
60 dayspremium payment grace period
Revision History & Legal Timelines
as writtenpolicy_procedure
Members must provide written notice identifying the dispute and reference specific contract provisions before initiating legal action; if disputed contractual claims are paid or resolved within 30 calendar days after receipt of notice, certain extracontractual or punitive damages are waived unless prohibited by law.
as writtenfraud_recovery
During the first two years of coverage, the issuer may demand repayment of benefits if a member commits fraud, misrepresentation, or knowingly provides false eligibility or claims information.
as writtenaccessibility_rights
Policy Summary
PayerCentene
PolicyIndividual Member EPO Evidence of Coverage
Policy CodePolicy AMB24-GA-C-00014
Change TypeNo material change
Effective Date
Next Review Date
Key ActionObtain required prior authorization before providing services that the Schedule of Benefits indicates require it to avoid reduced benefits.
Acute/intensive rehabilitation requires multidisciplinary therapies totaling three or more hours per day, five to seven days per week when billed as inpatient acute rehabilitation.
Special enrollment: qualified individuals generally have 60 calendar days to report qualifying events to enroll; loss of Medicaid/CHIP allows up to 90 days to enroll. Qualifying events and detailed reporting rules are described in the contract.
For marriage or loss of MEC, coverage is effective the first day of the following month unless otherwise specified.
Late notice: if a qualified individual did not receive timely notice of an event triggering SEP and was reasonably unaware, Georgia Access must allow plan selection within 60 days of when they knew or should have known of the event.
Non-network services may be subject to reduced benefits and balance billing unless protections apply; when protections apply, member cost share is calculated as if service provided by a network provider.
Outpatient medical supplies limits: prosthetics and orthotics, one pair of foot orthotics per year, four mastectomy bras per year, CPM machine post-joint surgery, rental of DME, infusion therapy, respiratory and cardiac rehab; prosthetic charges covered at no less than 80% of Medicare allowable.
Medication limits: refills prohibited if member has more than 15 days' supply on hand; split-fill dispensing limited to 15-day supplies for first 90 days for certain new therapies; extended day supply up to 90 days available for select maintenance meds via mail/order.
Lock-in program: members may be restricted to a single pharmacy and/or prescriber for safety/overutilization reasons; affected members are notified and have appeals rights.
Exclusions: multiple drug categories and circumstances are not covered (e.g., weight-loss drugs, erectile dysfunction drugs unless on formulary, investigational drugs, certain compound drugs, refills beyond allowed supply, Medicare Part D enrollees' drugs), as listed in the contract.
Non-network services when a network provider is not reasonably available may be authorized and covered at no greater cost to the member than network provider; otherwise non-network services generally are not covered and non-network providers may balance bill unless protections apply.
Automatic coverage periodCovered from time of birth or placement until the 31st day after birth or placement
Cost sharingEach newborn/adopted child service is subject to cost sharing per the Schedule of Benefits
Continuation requirementAdditional premium required to continue coverage beyond 31 days; notify within 31 days to enroll
inv-51: Deductible and cost sharing applicability — refer to Schedule of Benefits
Where to find amountsRefer to the Schedule of Benefits for specific deductible, coinsurance, copayment and OOP amounts
ApplicationDeductible, copayments and coinsurance apply as shown and cost sharing features govern payment responsibilities
Effect of non-network careAmount payable subject to determination of eligible expense and reductions for non-network providers per Schedule of Benefits
Duration thresholdMechanical ventilation for 21 consecutive days
Daily use requirement>= 6 hours per day
ContextCriterion applied for LTACH eligibility and ventilator management review
inv-53: Prosthetic payment floor — coverage no less than 80% of Medicare allowable
Minimum coverage levelCoverage provided shall be no less than 80% of the Medicare allowable (HCPCS referenced)
Applies toEligible outpatient prosthetic device charges and related supplies
ReferenceMedicare allowable as defined by CMS / HCPCS used to determine floor
inv-54: Supply limits — standard 30-day supply; select maintenance meds up to 90 days
Standard limitGenerally a 30-day supply per prescription
Extended supplySelect maintenance medications eligible for up to 90-day supply via mail order or select pharmacies
Specialty drugsSpecialty drugs and select categories limited to 30-day supply at retail or mail order
inv-55: Travel reimbursement eligibility distance — >60 miles to Center of Excellence
Eligibility distanceMember required to travel more than 60 miles from residence to Center of Excellence to qualify
Reimbursable itemsTransportation and lodging for member, donor and companions when travel threshold met (receipts required)
Reimbursement timingClaims/receipts must be submitted within six months of date of service for reimbursement
inv-56: Maximum ancillary reimbursement — $10,000 per transplant service
Maximum ancillary reimbursement$10,000 per transplant service
Included expensesTransportation, lodging, mileage reimbursement and approved ancillary items per member transplant reimbursement guidelines
DocumentationReceipts and mileage log required; arrange and submit per member resources page
inv-57: prior_authorization_timeframes — see provider_actions for specific timelines
See provider actionsRefer to authorization.provider_actions for specific prior authorization timeframes and submission methods (e.g., 5 days, 30 days, within 24 hours for inpatient admissions; urgent: 72 hours; non-urgent: 7 days)
Submission methodsPrior authorization requests accepted by telephone, eFax, or provider web portal
Consequence of noncomplianceFailure to obtain required prior authorization may reduce benefits; emergency services exempt
inv-58: Electronic clean claim payment timeframe (GA balance protections) — 15 working days
Electronic clean claims (GA)15 working days for payment of clean electronic claims under Georgia balance-billing protections
ScopeApplies to services that fall under Georgia state law balance billing protections
ContrastPaper clean claims have a different timeframe (see paper claim rule)
inv-59: Paper clean claim payment timeframe (GA balance protections) — 30 calendar days
Paper clean claims (GA)30 calendar days for payment of clean paper claims under Georgia balance-billing protections
ScopeApplies to services that fall under Georgia state law balance billing protections
ContrastElectronic clean claims paid within 15 working days
Notify Ambetter within 48 hours (or as soon as reasonably possible) of an emergency inpatient admission.
Failure to notify may affect coverage determinations for inpatient stays following an emergency.
Documentation Required
Notice and consent for non-network services
When services are furnished by a non-network provider and the member may waive balance-billing protections under the federal No Surprises Act, the non-network provider must provide the member with the written Notice and obtain the member's written consent (Notice and Consent) in the format required by law. The notice must be provided at least 72 hours before services for scheduled care (or at least 3 hours before services scheduled within 72 hours). The notice must include a good-faith estimate of charges, identify any prior authorization or limitations required, and clearly state that consent is optional and the member may seek care from a network provider. The member's written consent must acknowledge receipt of the notice and that payment of the non-network billed amount may not accrue toward the member's deductible or out-of-pocket maximum.
Notice must be given ≥72 hours before scheduled services (or ≥3 hours for services scheduled within 72 hours).
Notice must include: statement provider is non-network; good-faith estimate of charges; any prior authorization or limitations; statement that consent is optional.
Member must provide written consent acknowledging notice and understanding of potential cost-sharing implications.
Prior Authorization
Behavioral health prior authorization note
Outpatient behavioral health services (including IOP, PHP, individual and group treatment, MAT, medication management, psychological testing, outpatient detoxification, rehabilitation, ABA-based therapies, ECT, TMS, telehealth, and related services) are covered when medically necessary but may be subject to prior authorization. However, Ambetter will not require prior authorization for emergent inpatient withdrawal management services or emergent inpatient behavioral health treatment. Refer to the Schedule of Benefits for which behavioral health services require authorization.
Emergent inpatient withdrawal management and emergent inpatient behavioral health treatment do not require prior authorization.
Other outpatient and non-emergent behavioral health services may require prior authorization per the Schedule of Benefits.
SettingInpatient hospital, rehabilitation facility, or extended care facility
DefinitionAdverse benefit determination: a decision by the plan that results in denial, reduction, failure to provide or pay, determination of non-medical necessity, rescission, or related adverse outcomes as specified in the contract.
Appeals referenceMembers have rights to internal and external appeals as described in the contract's appeals procedures
ExamplesDenial of request for service; finding service not medically necessary; incorrectly calculated cost sharing; rescission
inv-87: Quality Improvement Committee — definition and role
Committee roleQuality Improvement Committee includes network providers to develop and monitor quality improvement program activities
StandardsProgram aligned with NCQA standards and National Academy of Medicine priorities
ActivitiesProvider checks, member reminders for preventive care, investigation of member concerns and annual member surveys
inv-88: Adverse benefit determination (expanded) — decisions resulting in denial/reduction/rescission etc.
Expanded definitionAdverse benefit determination includes decisions resulting in denial, reduction, failure to provide or pay, findings of non-medical necessity, rescission, or improperly calculated member cost sharing
ScopeIncludes prospective and retrospective review determinations and eligibility-based denials
Appeal pathwayRefer to Internal Grievance, Internal Appeals and External Appeals Procedures for appeal rights
inv-89: Medically necessary — definition and criteria
DefinitionMedically necessary: services consistent with generally accepted standards of medical practice, appropriate in scope/duration/intensity, not custodial, not experimental, and provided in the most cost-effective setting.
Hospital confinementFor inpatient care, means diagnosis and treatment cannot be safely provided as outpatient
ConsequencesCharges for treatment not medically necessary are not eligible expenses
inv-90: Notice and consent — definition around No Surprises Act conditions
DefinitionNotice and consent: written notice and voluntary written consent from a member that allows limited waiver of balance billing protections for scheduled non-network services when federal requirements are met.
Timing requirementsNotice provided at least 72 hours before services, or at least 3 hours if scheduled within 72 hours; consent must be documented and provided in required format
LimitationsNotice and consent cannot waive protections for emergency services, certain ancillary services, or when member unable to consent as determined by attending physician
inv-91: Notice and consent (detailed) — timing and conditions for non-network notice/consent
Timing and conditionsThe non-network provider must deliver written notice at least 72 hours before services (or 3 hours if within 72 hours) and obtain voluntary written consent that documents acknowledgement of potential balance billing and effects on deductible/OOP
DocumentationSigned notice and consent including time/date must be provided to member and copy given via email or mail
ExceptionsCannot waive protections for emergency services, air ambulance without network option, or many ancillary services unless additional conditions are met
Non-network providerA provider not listed in the plan's current network; services generally not covered except as stated in contract
Non-network eligible expenseThe eligible expense for services or supplies provided and billed by a non-network provider; member may be balance billed unless protections apply
ExceptionsEmergency services, air ambulance, and certain non-emergency services at network facilities may be covered as non-network eligible expenses per contract
inv-93: Orthotic and prosthetic devices — definitions
Orthotic deviceA medically necessary device to support, align, prevent or correct deformities and assist function; used for therapeutic support and restoration
Prosthetic deviceA medically necessary device used to replace, correct or support a missing portion of the body or to prevent/correct deformity or malfunction
Covered componentsCasting, molding, fittings, adjustments, repairs and appropriate taxes/shipping included when medically necessary
inv-94: Prior authorization — definition (short)
Short definitionPrior authorization: a decision to approve specialty or other medically necessary care in advance of services
Not guaranteeAuthorizations are not a guarantee of payment; benefits remain subject to contract terms and Schedule of Benefits
SubmissionRequests accepted by telephone, eFax, or provider web portal as outlined in prior authorization procedures
inv-95: Dependent and enrollment rules — definition summary
Dependent effective datesDependent members become eligible on event-specific dates (e.g., birth, placement for adoption, marriage) as specified in contract
Newborn/adopted temporary coverageAutomatic coverage for newborns and adopted children for up to 31 days from event
Special enrollment windowsQualified individuals generally have 60 days to report qualifying events (90 days for Medicaid/CHIP loss)
inv-96: Stabilize / Post-stabilization services — definition
Stabilize definitionStabilize: provide medical treatment necessary to assure no material deterioration is likely during transfer or discharge; post-stabilization are services after stabilization
ApplicationPost-stabilization services may be part of outpatient observation or inpatient/outpatient stay linked to the emergency visit
inv-97: episode of care — definition
Episode of careServices provided by a health care facility or provider to treat a condition or illness; claims for an episode are processed separately as received
Claim handlingEach claim adjudicated separately according to cost share and Schedule of Benefits
inv-98: cost sharing — definition of coinsurance/copayment/deductible and OOP application
Cost sharing componentsCoinsurance: member share applying to OOP but not deductible; Copayment: fixed amount due at time of service applying to OOP but not deductible; Deductible: amount member must pay before benefits apply
Maximum out-of-pocketMember pays copayments, coinsurance and deductible until reaching maximum OOP shown in Schedule of Benefits; family OOP = 2x individual OOP
Schedule referenceSpecific amounts and applicability shown in Schedule of Benefits
inv-99: Balance billing protections (No Surprises Act) — definition and protections summary
DefinitionBalance billing protections (No Surprises Act): federal protections that prohibit balance billing for certain emergency services, air ambulance services, and certain non-emergency services at network facilities unless valid notice and consent obtained
Member cost shareWhen protections apply, member pays cost share calculated as if services were from a network provider based on recognized amount
LimitsNotice and consent process must meet strict timing and content requirements to waive protections; many ancillary services cannot be waived
inv-100: PCP — Primary Care Physician definition and role
DefinitionPrimary Care Physician (PCP): a network provider designated by the member who coordinates preventive care, referrals, and ongoing care
ScopePCPs include family practitioners, internists, pediatricians, OB/GYNs, APRNs, PAs; members may change PCP no more than once per month
ResponsibilitiesProvide preventive care, coordinate specialty referrals (except behavioral health and OB/GYN), after-hours guidance, and maintain medical records
inv-101: Durable medical equipment — definition
DefinitionDurable medical equipment (DME): equipment that can withstand repeated use, is primarily for a medical purpose, not useful without illness/injury, appropriate for home use (e.g., wheelchairs, hospital beds, oxygen equipment)
Payment rulesRental or purchase at plan discretion; rental costs not to exceed purchase price; delivery/installation covered; DME subject to prior authorization
SuppliesMedically fitting supplies included with rental; owned equipment supplies may be billed separately
inv-102: Clinical Trial Coverage — definition and included routine costs
DefinitionClinical Trial Coverage: routine patient care costs for qualifying phase I–IV clinical trials undertaken for prevention, early detection or treatment of cancer or other life‑threatening diseases when trial/site meets specified accreditation/funding criteria
Covered itemsRoutine care costs and reasonable medically necessary services to administer the trial; excludes items provided solely for data collection or provided free by sponsor
AuthorizationParticipation in clinical trials is subject to authorization requirements per contract
inv-103: Rehabilitation limits — therapeutic benefit and treatment cessation definition
Rehabilitation limitsRehabilitation ceases when further treatment cannot restore function beyond current level, member has reached maximum therapeutic benefit, no measurable progress toward documented goals, or care is primarily custodial
ApplicationLimits apply to inpatient and outpatient rehabilitation and confinement in extended care facilities; see Schedule of Benefits for benefit levels
AssessmentDetermination made by plan per medical necessity and documented goals
inv-104: Newborns' and Mothers' Health Protection Act rights — federal minimum hospital stay definition
Federal minimum stayFederal law: minimum hospital stay of 48 hours after vaginal delivery and 96 hours after cesarean delivery unless mother and provider agree to earlier discharge
No prior authorization requiredProvider may discharge earlier after consulting mother; plan may not require authorization for length of stay up to federal minimum
Newborn cost sharingNewborn services are subject to separate cost sharing per Schedule of Benefits
inv-105: Newborn Charges — definition and separate cost-sharing for newborns
DefinitionNewborn Charges: medically necessary services provided to a covered newborn immediately after birth; each type of service subject to its own cost sharing
Temporary coverageNewborn automatically covered for 31 days from birth; additional premium required to continue beyond 31 days
Enrollment noticeIf notify within 60 days, plan may not deny coverage for failure to pre-enroll; see Dependent rules for details
inv-106: Federal right to minimum hospital stay — 48/96 hours unless agreed otherwise
Federal rightMembers entitled to minimum hospital stay of 48 hours (vaginal) or 96 hours (cesarean) unless earlier discharge agreed by mother and provider
Plan limitationPlan may not require authorization for a length of stay not exceeding federal minimums
ApplicabilityApplies to mother and newborn in connection with childbirth
inv-107: Low-protein food products — definition for metabolic disease management
DefinitionLow-protein food products: specially formulated foods with less than specified grams of protein per serving used under physician direction to treat inherited metabolic diseases (e.g., PKU, MSUD)
DefinitionBalance-on-hand: the cumulative on-hand supply of medication a member possesses; refills prohibited until balance-on-hand is equal to or fewer than 15 days' supply
Refill restrictionMedication refills prohibited when member has more than 15 days' supply on hand
inv-110: Lock-in — lock-in program definition
DefinitionLock-in program: program restricting identified members to a specific pharmacy and/or prescriber to reduce overutilization and abuse
Notification and rightsMembers notified by mail of participation, duration, pharmacy/prescriber restrictions and appeals rights; requests to change may be reviewed
inv-111: Self-injectable Drugs — definition and coverage note
DefinitionSelf-injectable drugs: medications delivered into muscle or under the skin with a syringe and needle; covered under prescription drug benefits with standard prescription cost share
AdministrationAlthough initial supervision or instruction may be needed, patient or caregiver can self-administer; coverage subject to formulary and prior authorization rules
inv-112: Exigent circumstances for expedited exception — definition
DefinitionExigent circumstances for expedited exception: situations where member's life, health, or ability to regain maximum function is seriously jeopardized or when undergoing current course of treatment using a nonformulary drug
Expedited timeframeExpedited exception determinations provided within 24 hours of receipt
DefinitionUtilization review: process including pre-service/prior authorization review, concurrent review during care, and retrospective review after services are provided
PurposeUsed to monitor medical necessity, appropriateness, efficacy and efficiency of services and settings
TimeframesReviews follow specified timeframes (urgent, non-urgent, retrospective) and may affect payment/benefits
inv-114: Ambetter Health Perks program — vendor discount program definition
DefinitionAmbetter Health Perks program: an optional vendor discount program offering discounts, financial tools (including zero-interest line of credit), and wellness-related services administered by vendors; members pay for discounted goods/services
AdministrationProgram vendors administer offers directly; Ambetter does not endorse vendors and is not involved in program administration
inv-115: custodial parent — definition
DefinitionCustodial parent: parent awarded custody by court/administrative order; upon request insurer will provide custody parent with contract information and accept claims/payments
RightsCustodial parent may submit claims and receive payments directly upon provision of custody order
inv-116: eligible complainant — definition
DefinitionEligible complainant: the claimant, a person authorized to act on claimant's behalf, spouse/family/treating provider if claimant unable to consent, or verbally authorized representative in expedited appeals
Appeal filingWritten authorization not required for authorized representative; representatives may file internal appeals on claimant's behalf
inv-117: Appeal — definition of appeal process and scope
DefinitionAppeal: a formal request (oral, written, or electronic) to reconsider an adverse determination not to certify an admission, extension or other health care service; includes standard and expedited appeals
ProcessAppeals follow ACA internal appeals processes; filing windows and timeframes detailed in appeals section
inv-118: Complaint — definition of complaint
DefinitionComplaint: a communication (oral, written, or electronic) expressing dissatisfaction with the health plan or its providers, including service quality and access issues
ResolutionContact Member Services to resolve complaints; formal complaint procedures available when initial contact does not resolve issue
inv-119: Eligible Complainant / Authorized Representative — who may file appeals
Who may fileEligible Complainant / Authorized Representative: claimant, authorized representative (written authorization not required), spouse/family/treating provider if claimant cannot consent, or verbally-authorized rep for expedited appeals
Filing methodsAppeals/complaints may be filed orally, in writing or electronically; Member Services can assist
inv-120: Construction — insurer discretion to interpret contract provisions
DefinitionConstruction: insurer's discretion and authority to construe and interpret contract provisions to the fullest extent allowed by law
ApplicationInterpretation exercised within applicable state and federal law boundaries
inv-121: Personal Health Information (PHI) — HIPAA privacy standard statement
DefinitionPersonal Health Information (PHI): all oral, written and electronic personal health information protected in accordance with HIPAA and the plan's Notice of Privacy Practices
Member rightsMembers may request the full Notice of Privacy Practices via website or Member Services; plan follows HIPAA requirements
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Members who are not proficient in English or who have auditory/visual impairments have the right to free, timely language assistance and auxiliary aids via Member Services at 1-877-687-1180 (TTY 1-877-941-9231).