Centene Ambetter EPO Evidence of Coverage | OpenPayer
CurrentCentenePolicy N/A
Individual Member EPO Contract / Evidence of Coverage
This document is an Evidence of Coverage (member contract) describing benefits, member rights and responsibilities, access to care, prior authorization, and administrative provisions for Ambetter Health Solutions members; it governs individual EPO members covered by Ambetter (Peach State Health Plan, Inc.).
Policy Summary
PayerCentene
PolicyIndividual Member EPO Contract / Evidence of Coverage
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization via phone, eFax or provider portal before providing services that the Schedule of Benefits lists as requiring authorization.
No material clinical or coverage changes in this revision.
1-833-543-3145Member Services phone
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60-dayPremium grace period
Nov 1–Jan 15Open enrollment
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Coverage, Eligibility, Benefits and Limits
Coverage overview
Coverage and benefit sections are detailed in the Table of Contents and governed by the Schedule of Benefits and contract provisions. Prior authorization may be required for some services.
Covered services, limits, cost sharing and any prior authorization requirements are described in this Evidence of Coverage and the member's Schedule of Benefits.
Coverage rules and definitions
Emergency and non-network service coverage rules, notice and consent for waiving balance billing protections, and related member obligations.
Emergency services are covered without prior authorization and include facility costs, physician services, supplies and prescription drugs charged by that facility; members or providers must notify Ambetter within 48 hours (or as soon as reasonably possible) if admitted as an inpatient following emergency care.
Non-network providers are not covered except as specifically stated (e.g., emergency services, non-emergency services at a network facility, air ambulance, or other situations described in the contract). When balance billing protections apply, members are responsible only for the member cost share calculated as if services were from a network provider.
Notice and consent (No Surprises Act) requirements to waive balance-billing protections require a written notice in the format required by law, provided at least 72 hours prior (or at least 3 hours for services scheduled within 72 hours), voluntary written consent including acknowledgement of potential balance billing and effect on cost-sharing, and provision of copies to the member; specified exceptions (emergency services, ancillary services, and others) mean notice and consent will not waive protections in those circumstances.
Eligible expense for network providers equals the contracted fee; eligible expense for non-network providers is determined in accordance with the contract and applicable law and may be reduced for services rendered by non-network providers except where balance-billing protections apply.
Acute rehabilitation requires an intensive multidisciplinary program with therapies performed at least 3 hours per day, 5–7 days per week when delivered as acute inpatient rehabilitation.
Eligibility & Effective Date Criteria
Eligibility, effective dates, and termination rules for subscribers and dependent members.
Dependent members become eligible on the later of the subscriber's effective date or the event-specific date (e.g., marriage, birth, placement for adoption, foster placement, or domestic partnership).
Dependent members included in the initial enrollment application are covered on the same date as the subscriber's initial coverage date.
Newborns are covered from time of birth until the 31st calendar day after birth; additional premium is required to continue coverage beyond 31 days; if notice of the newborn is given within 60 calendar days of birth, the insurer may not deny coverage for failure to pre-enroll.
Placed-for-adoption children are covered from date of placement until the 31st calendar day after placement; additional premium and notification deadlines apply (notify within 60 days and pay additional premium within 90 days to avoid retroactive premium charges).
If a member is inpatient on the effective date and prior coverage continues to furnish benefits, services are not covered under this contract until discharge or exhaustion of prior benefits; if no prior coverage continuation, Ambetter coverage applies but the member must notify Ambetter within two calendar days for review and authorization; non-network hospital claims will be paid at Ambetter allowed amount and member may be billed the balance.
Special Enrollment Criteria
Special Enrollment Period eligibility and effective date rules
Regular effective date: coverage is effective on the first of the month following plan selection unless a special-event rule applies.
Immediate effective events
Birth, adoption, placement for adoption, or foster care — coverage effective on date of event.
Marriage or loss of minimum essential coverage — coverage effective the first day of the following month (subject to documentation rules).
If a qualified individual did not receive timely notice of a triggering event, they may select a new plan within 60 calendar days from the date they knew or reasonably should have known of the event; at the plan's option the earliest effective date that would have applied may be provided.
Premium Payment Criteria
Premium payment and third-party payment policies
Premiums are due on or before their due date; the initial premium must be paid prior to the coverage effective date; monthly premiums are due on or before the first of each month.
There is a 60-calendar-day premium grace period; during the grace period the contract remains in force but claims may pend and providers will be notified of possible denials.
Acceptable third-party payers are limited (consistent with CMS guidance) and include Ryan White Program, Indian tribes/tribal organizations, state/federal programs, certain tax-exempt organizations, family members, an employer for an ICHRA/QSEHRA, and qualifying private foundations meeting criteria.
Cost Sharing & Network Billing
HSA, cost sharing, and non-network billing rules
HSA: members must meet federal HSA eligibility to open/contribute to an HSA; the plan does not act as HSA trustee and members are responsible for complying with federal HSA rules.
Coinsurance: member share of covered service cost; coinsurance does not apply toward the deductible but does apply toward the maximum out-of-pocket; after individual OOP is met the plan pays 100% for that member.
Copayments: fixed dollar amounts due at time of service; copayments do not apply toward the deductible but count toward the maximum out-of-pocket.
Deductible: member must satisfy any applicable deductible shown in the Schedule of Benefits before certain benefits are paid; copayments and coinsurance do not count toward the deductible.
Maximum out-of-pocket: individual and family maximums are shown in the Schedule of Benefits; family maximum equals two times the individual maximum; once a member meets individual OOP they no longer owe cost sharing for the remainder of the calendar year.
Coverage criteria and rules (excerpt)
Covered services and limitations described in these sections include essential health benefits, specific benefit limits, and requirements for medical necessity and prior authorization where noted.
All covered services must be medically necessary and not experimental or investigational; benefit limits, exclusions and prior authorization requirements apply as described in the contract.
Under federal law effective Jan 1, 2022, members are protected from balance billing for services subject to balance-billing protections and are responsible only for member cost share calculated as if services were from a network provider.
Members must designate a network primary care physician (PCP); if none selected one will be assigned; members may change PCP no more frequently than once per month and changes take effect within 30 calendar days.
Access and emergency rules
Emergency services are covered 24/7 both in and out of the service area; emergency providers may be non-network but are subject to balance-billing protections.
Ambulance Coverage Criteria
Ambulance services coverage and limits
Air ambulance
Air ambulance covered for emergency transport to the nearest appropriate hospital or neonatal special care unit, authorized inter-hospital transfers, when ordered by certain officials if member cannot refuse, or when required by the plan to move a member from a non-network to a network provider.
Non-emergency air ambulance requires prior authorization; prior authorization is not required for air ambulance transport when the member is experiencing an emergency condition; covered air ambulance services should not result in balance billing.
Exclusions include air ambulance services covered by a local governmental body (unless required by law), non-emergency air ambulance without authorization, air transport outside/into the U.S., services for comfort/convenience, and non-emergency commercial flights.
Ground and water ambulance
Autism Spectrum Disorder
Autism Spectrum Disorder services coverage
Coverage includes evaluation and assessment, applied behavior analysis (ABA) therapy, behavior training/management, habilitation, speech/OT/PT, psychiatric care and medications/nutritional supplements; there is no specified limit on ABA services, but ABA is subject to prior authorization to determine medical necessity; separate cost sharing may apply when multiple providers deliver services on the same day.
DME/Prosthetics/Orthotics
Durable Medical Equipment, Supplies, Orthotics, Prosthetics coverage and limits
Durable medical equipment (DME) may be rented or purchased; rental costs must not exceed the purchase price and the plan will not pay rental longer than the purchase cost; delivery, installation, repair, adjustment and replacement may be covered when medically necessary; DME and certain rentals are subject to prior authorization.
Exclusions for DME include comfort/convenience items and items normally stocked for home use (e.g., air conditioners, raised toilet seats, treadmills), and rental of equipment when member is in a facility expected to provide such equipment.
Prosthetics covered include purchase, fitting, necessary adjustments, repairs and replacements when medically necessary (examples include LVAD as bridge to transplant, breast prosthesis after mastectomy); prosthetic devices should be purchased rather than rented and reimbursement guidance references Medicare/HCPCS standards where applicable.
Orthotic devices: coverage includes initial purchase, fitting and repair of custom rigid or semirigid orthotics; generally one orthotic device per affected limb per year when medically necessary, with additional replacements for growth or irreparable damage; casting, molding and fittings included when billed with the orthotic.
Clinical Trials
Clinical trial coverage criteria
Routine patient care costs in approved Phase I–IV clinical trials for prevention, early detection, or treatment of cancer or life‑threatening disease are covered when the trial meets listed approval/funding criteria; coverage includes FDA‑approved drugs/devices used in the trial and medically necessary services to administer them, but excludes investigational items, items provided solely for data collection, or items customarily provided free by sponsors.
Phase I/II trials must be sanctioned by NIH or NCI and conducted at academic/NCI centers as described; Phase III/IV trials must be approved or funded by specified federal agencies, IRBs or qualified non-governmental entities enumerated in the contract.
Treating facilities and personnel must have appropriate expertise and volume; informed consent per legal/ethical standards is required; participation in clinical trials is subject to prior authorization requirements.
Diabetes, Dialysis, and Supplies
Additional covered services
Diabetic care: medically necessary diabetic services and prescribed supplies are covered including exams, routine foot care, lab testing, self‑management equipment (glucometers and supplies), orthotics/diabetic shoes, education and training by certified professionals.
Dialysis: medically necessary acute and chronic dialysis services are covered in outpatient facilities, hospital settings and home dialysis after training; equipment/supplies for home dialysis are covered and purchase versus rental determined by the plan and authorization may be required.
Disposable medical supplies with a primary medical purpose are covered subject to reasonable quantity limits and applicable member cost sharing (deductible, copayment, coinsurance).
Emergency Services and Family Planning
Emergency and family planning coverage
Emergency services
Emergency services are covered 24/7 both in and out of the service area; for behavioral health emergencies call 988 or go to nearest ER.
Emergency providers may be non-network but services are subject to balance-billing protections and non-network emergency providers may not balance bill members for the difference between allowed amount and billed amount.
Family planning and contraception: preventive family planning services are covered without cost sharing when provided by a network provider and legal under applicable law; coverage includes the full range of FDA‑identified contraceptives, counseling, screening, follow‑up care and related services (including anesthesia integral to sterilization procedures).
Emergency Services
Emergency services
Emergency services are covered 24 hours a day, seven days a week both in and out of the plan service area; members should call 911 or, for behavioral health emergencies, call 988 or go to the nearest ER; non-network emergency providers are subject to balance-billing protections.
Family Planning and Contraception
Family planning and contraception
Preventive family planning and contraception services are covered without cost sharing when provided by a network provider and lawful under applicable law; covered items include sterilization, IUDs, implants, injectables, oral contraceptives, patches, rings, diaphragms, condoms, spermicides, emergency contraception, counseling, screening, follow-up and fertility awareness instruction.
Fertility Preservation
Fertility preservation
Medically necessary standard fertility preservation services are covered when treatment poses a risk of iatrogenic infertility; coverage includes evaluation, laboratory assessments, medications, treatments and gamete storage up to one year; prior authorization may be required and the member is responsible for continued storage if coverage terminates during the storage period.
Habilitation/Rehabilitation
Habilitation, Rehabilitation and Extended Care
Rehabilitation and extended care services are covered when medically necessary; benefits include inpatient and outpatient rehabilitation therapies, provider and facility charges limited as specified, and services cease when maximum therapeutic benefit is reached or care becomes custodial; prior authorization may be required.
Home Health Care
Home health care
Home health care services are covered when physician indicates the member is unable to travel to the provider; covered services include home health aide services, professional therapy in the home, intravenous medications, hemodialysis, medically necessary supplies and DME rental/purchase rules; home health care is subject to prior authorization; respite, custodial and educational care are excluded.
Hospice Care
Hospice care
Hospice benefits for terminally ill members cover room and board (up to the hospice's most common semiprivate rate), therapies, equipment rental, palliative/supportive care, counseling and bereavement services; benefits for hospice inpatient, home and outpatient care are subject to authorization and respite care charges are excluded.
Medical and Surgical Benefits
Medical and surgical expense benefits
Covered medical and surgical services include surgery, pre/post‑operative testing, laboratory and imaging, genetic/biomarker testing (when meeting coverage criteria), chemotherapy (including oral), radiation, DME and prosthetics, anesthesia, reconstructive surgery (including post‑mastectomy), certain dental surgery circumstances, infertility diagnosis/testing, routine clinical trial care, telehealth services, cochlear implants, cardiac/respiratory/rehabilitation therapies, early intervention for children 0–36 months, lymphedema treatment, chiropractic outpatient care, immunizations and newborn screenings; these services are subject to medical necessity, prior authorization where noted, and Schedule of Benefits cost sharing and limits.
Long-Term Acute Care
Long-term acute care (LTACH)
LTACH is appropriate for clinically complex patients requiring extended hospital‑level care; examples include complex wound care, intensive infectious disease management, multiple comorbidities requiring monitoring, rehabilitation needs not met in SNF, and mechanical ventilation criteria (failed weaning and mechanical ventilation for 21 consecutive calendar days for six or more hours per day); ventilator management must occur at least every four hours and LTACH benefits are subject to prior authorization.
Lymphedema Benefit
Lymphedema
Lymphedema treatment is covered when prescribed by a licensed physician or rendered in an authorized facility and includes multilayer compression bandaging systems and custom or standard-fit gradient compression garments.
Maternity and Newborn Care
Maternity, newborn and surrogate rules
Maternity: minimum inpatient stay covered is 48 hours for vaginal delivery and 96 hours for cesarean delivery; some maternity services may require prior authorization; newborn services are covered immediately after birth and each newborn's services are subject to separate cost sharing as shown in the Schedule of Benefits.
Surrogacy: services or supplies related to a member acting as a surrogate are not covered; surrogates must notify the insurer within 30 calendar days of enrollment or agreement to participate in a surrogacy arrangement to avoid potential recoupment for fraud/misrepresentation.
Covered Benefits and Pharmacy Program Criteria
Covered services and program rules include medical/surgical procedures, diagnostic imaging, telehealth parity, therapies, vision, mental health/substance use services, prescription coverage, and pharmacy program controls.
Prescription drug benefits include coverage for prescription drugs dispensed by licensed pharmacies, oral anticancer medications (with parity to IV/injectable cancer medications), and off‑label uses when supported by standard compendia or evidence as described; pharmacy program controls include mail-order and 90‑day supplies for eligible maintenance drugs, a Lock‑In program restricting pharmacy/prescriber for members meeting criteria, and quantity/supply limits as specified.
Radiology, imaging and diagnostic testing are covered when medically necessary; prior authorization may be required and services may generate separate technical and professional component charges.
Behavioral health and substance use disorder services are covered in parity with physical health benefits; utilization management uses InterQual and ASAM criteria and services should be provided in the least restrictive clinically appropriate setting.
Telehealth services are covered when medically necessary and subject to the same cost sharing as in‑person services unless provided through specified virtual programs.
Pharmacy and Select Medical Coverage Criteria
Prescription drug coverage and exclusions
Prescriptions may be filled at network retail pharmacies or via in‑network mail order; certain maintenance drugs are eligible for a 90‑day supply by mail or participating retail pharmacies; specialty drugs and select categories are generally limited to a 30‑day supply.
Mail‑order is available for eligible prescriptions and delivery is provided at no extra charge though regular copay/coinsurance applies; enrollment information available on the website.
Pharmacy Lock‑In program: members meeting criteria may be restricted to a single network pharmacy, specialty pharmacy, or prescriber for controlled substances; only prescriptions filled/prescribed under these restrictions are considered eligible covered expenses; members and providers will be notified and may request changes or appeals.
Non‑covered drug categories and exclusions include erectile dysfunction drugs (unless on formulary), weight‑loss drugs (unless on formulary), investigational drugs, certain institutional or foreign prescriptions, vitamins (unless on formulary), infertility drugs (unless on formulary), cannabis, refills when member has >15 days on hand, compound drugs without an FDA‑approved ingredient, and other specified exclusions.
Coverage criteria (partial)
Covered services and conditions where benefits apply
Sleep studies are covered when medically necessary and may be performed at home or in a facility; prior authorization may be required.
Transplant services are covered when the member is accepted as a transplant candidate and pre‑authorized through a Center of Excellence or approved facility; authorization is required before evaluation and related services; covered transplant expenses include pre‑transplant evaluation, organ harvesting, LVAD as bridge to transplant, pre‑transplant stabilization, acquisition cost when authorized, the transplant itself, post‑transplant follow‑up, donor search/testing and donor expenses as specified.
Center of Excellence travel and lodging reimbursement: when required to travel more than 60 miles to a Center of Excellence for transplant, Ambetter will reimburse up to $10,000 per transplant service for transportation, mileage (with log), lodging and approved items with receipts submitted within six months; specific exclusions and documentation rules apply.
OB/GYN access exception: members do not need prior authorization to access in‑network obstetrical or gynecological practitioners though certain services performed by those practitioners may still require authorization.
Non-Network Services Authorization
Services from non-network providers
Except when balance‑billing protections apply, services from non‑network providers are not normally covered; if a covered service cannot be obtained from a network provider within a reasonable distance, authorization may be provided to obtain the service from a non‑network provider at no greater cost than network provider; prior authorization must be requested before receiving non‑network services or the member may be responsible for all charges.
Prior Authorization Criteria
Prior authorization requirements and exceptions
Some medical and behavioral health services require prior authorization; network providers generally must obtain authorization before providing services listed on the Schedule of Benefits.
Timing and submission
Submit prior authorization requests by telephone, eFax or provider web portal.
Timing: at least 5 calendar days prior to elective inpatient admission and start of home health (except post‑discharge); at least 30 calendar days prior to initial transplant evaluation and clinical trial services; within 24 hours of any inpatient admission (including emergent); and at least 5 days prior to elective admissions as specified.
Decision timeframes
Urgent concurrent/urgent pre‑service reviews: decision within 24–72 hours depending on request type; non‑urgent pre‑service reviews within 7 calendar days; retrospective/post‑service reviews within 30 calendar days.
Claims and Appeal Criteria
Key coverage and procedural criteria extracted from document portion:
Time for payment of claims: benefits processed within 30 calendar days after receipt of proper proof of loss for services not under Georgia balance‑billing protections; for Georgia balance‑billing protected clean electronic claims payment within 15 business days (30 calendar days for paper).
Emergency services while traveling outside U.S.: covered up to 90 consecutive days; claims must be submitted within 180 calendar days with English documentation and proof of travel.
Appeals: members have 180 calendar days from the date of adverse benefit determination to file an internal appeal; the plan will notify required information within five business days of receipt; appeal decision timeframes include 30 days for pre‑service, 60 days for post‑service, and 72 hours for certain prescription drug/formulary appeals; the plan may extend by up to 14 days if additional information is needed.
Grievance panel: the panel excludes the initial decision‑maker and includes at least one physician (not the medical director) and at least one other licensed provider competent in the treatment/procedure; consultants with relevant expertise will be used when medical judgment is involved.
Appeals, External Review and Complaint Criteria
Filing and resolution rules for external reviews and complaints with timeframes and submission methods.
External review (standard): requests must be filed within four months of receiving the final internal appeal determination (contract also lists 120 days in timeline); standard external review resolution within 45 days; submission methods include mail, fax or online portal to the designated vendor (contact details provided).
Expedited external review
Eligibility: life‑threatening condition, hospitalized members, denials of prescription drugs or IV infusions, denied step therapy exceptions, or when an expedited internal appeal is requested; resolution timeframe: within 72 hours.
Simultaneous expedited process: members or authorized representatives may request expedited internal appeal and expedited external review at the same time for urgent care; vendor contact (MAXIMUS Federal Services) and phone number provided.
Complaint filing: complaints acknowledged within 5 business days and resolved within 30 calendar days (with allowable 14‑day extension); submissions via Member Services phone, written mail, Grievance and Appeal Form, or fax with contact details and required information listed in member materials.
Coding, Billing References and Key Values
Table of Contents references to benefit sectionsmixed
No codes listed
Allowed amount / Eligible expense guidancemixed
Allowed amount/Eligible expense definitions: For network providers the eligible expense is the contracted fee; for non-network providers eligible expense is negotiated fee when balance-billing protections apply or reimbursement as determined by Ambetter and applicable law; member may be balance billed when protections do not apply.
Not present in this sectionmixed
No codes listed
Schedule of Benefits referencesmixed
Refer to the Schedule of Benefits for deductible amounts, coinsurance percentages, copayments, maximum out-of-pocket amounts and specific benefit limits.
Ambulance servicesmixed
No codes listed
Referenced coding/billing guidancemixed
Prosthetic reimbursement guidance references Medicare allowable and HCPCS for comparison; prosthetic devices should be purchased rather than rented and reimbursement limited to medically necessary standard items.
No explicit CPT/HCPCS/ICD codes provided in this sectionmixed
No codes listed
Anticancer Medication CoveragemixedCovered
Prescribed oral anticancer medications are covered; coverage shall be no less favorable than for intravenously administered or injected cancer medications.
Imaging services billing componentsmixed
No codes listed
services referenced (no codes provided)mixed
Sleep studies, transplant evaluations and related transplant services are referenced; prior authorization may be required and technical/ professional components may generate separate charges.
Claims Submissionmixed
Providers typically submit claims on member's behalf; member reimbursement requests require detailed claim and Member Reimbursement Claim Form submitted to Ambetter Health, Attn: Claims Department, P.O. Box 5010 Farmington, MO 63640-5010.
Claim timing rulesmixed
Time for payment: For services not under Georgia balance-billing protections, benefits processed within 30 calendar days after receipt of proper proof of loss. For services under Georgia balance-billing protections, paid within 15 business days for clean electronic claims or 30 calendar days for clean paper claims. Emergency services outside the U.S. covered up to 90 consecutive days; claims submitted within 180 calendar days.
Out-of-Pocket/Cost Share references
Where to find specificsSee the Schedule of Benefits for exact copayments, deductibles, coinsurance percentages and individual/family out‑of‑pocket maximums.
Cost‑sharing componentsCost sharing includes deductible, copayments and coinsurance; copays and coinsurance apply to OOP but not to deductible as specified in Schedule of Benefits.
Family OOP interactionFamily maximum out‑of‑pocket is two times the individual maximum; individual reaching their OOP will pay no more cost share for remainder of calendar year.
Prior Authorization, Notifications and Provider Responsibilities
Prior Authorization
Prior Authorization Required
Some services require prior authorization. Benefits may be reduced or not covered if prior authorization requirements are not met. Refer to the Schedule of Benefits and the Prior Authorization provisions for services that require authorization.
Note
Authorization and Emergency Notification / Post-stabilization Notice and Consent Conditions
If a member receives emergency services resulting in an inpatient admission, the provider or member must notify the plan within 48 hours or as soon as reasonably possible. Emergency services are covered without prior authorization; however, continuation of care beyond stabilization is not considered emergency care and requires authorization to be covered. Post-stabilization services furnished by a non-network provider may only waive balance-billing protections if all Notice and Consent conditions are met and the attending physician determines the member can be safely transferred or is capable of providing informed consent. The provider must ensure the member (or authorized representative) is in a condition to provide voluntary, informed written consent, and the notice/consent documents are provided and retained in the required format and timelines.
Notify the plan within 48 hours of an inpatient admission resulting from emergency services.
Terms and Definitions
Definitions (contract)
Definitions section instructionMany words used in the contract have special meanings; members should refer to the Definitions section for defined terms used throughout this contract.
Contract componentsThis contract, the application, the Schedule of Benefits, and any amendments/riders together constitute the entire contract under which covered services are provided.
Use guidanceBecause provisions are interrelated, members should read the entire contract to understand coverage, limitations, and exclusions.
Member rights
Right to participate in care decisionsMembers have the right to participate with providers in decisions about their health care, including informed discussion of treatment options and risks.
Access and non‑discrimination
Policy Summary
PayerCentene
PolicyIndividual Member EPO Contract / Evidence of Coverage
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain required prior authorization via phone, eFax or provider portal before providing services that the Schedule of Benefits lists as requiring authorization.
Open enrollment occurs annually; example initial open enrollment dates provided (Nov 1, 2025 – Jan 15, 2026) with effective date rules for enrollments on or before Dec 15, 2025.
Regular effective dates are the first of the month following plan selection except for specified special events where effective date may be the date of event (birth, adoption, foster placement) or first day of following month as described.
Qualifying events include loss of minimum essential coverage, gaining dependents (marriage, birth, adoption, foster placement), erroneous enrollment due to error, plan material violation, permanent move, ERISA section 603 events, domestic abuse, Medicaid/CHIP determinations, new access to ICHRA/QSEHRA, COBRA subsidy cessation, and loss of premium subsidy for On-Exchange plans.
How to apply: contact Member Services or the state enrollment entity (e.g., GeorgiaAccess) for SEP determinations; phone number provided in member materials.
Non-network/balance billing: non-network providers may bill members for the difference between plan payments and billed charges (balance billing) unless balance-billing protections apply; when protections apply member pays only network-equivalent cost share.
Non-emergency services received from an Ambetter provider outside the service area may require prior authorization.
When receiving care at a network hospital some hospital-based providers may be non-network; members may not be balance billed for non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic services) provided by non-network providers at a network hospital.
Certain services (e.g., acupuncture outpatient by network providers, acquired brain injury post-acute rehab, and other listed benefits) are covered subject to medical necessity and Schedule of Benefits limits.
Ground and water ambulance covered for emergency transport to the nearest appropriate hospital, neonatal transfers, authorized inter-hospital transfers, when ordered by officials if the member cannot refuse, or when required to move the member from non-network to network provider.
Prior authorization is not required for emergency ground or water ambulance; non-emergency ambulance transportation requires prior authorization; unless required by law non-network ambulance providers may balance bill.
Exception processes: members/providers may request standard (72‑hour) or expedited (24‑hour) exceptions for non‑formulary drugs and step‑therapy exceptions with specified decision timeframes; determinations and appeals follow the contract's timelines and external review rights.
If additional information is needed, timeframes may be extended consistent with applicable law; failure to obtain required prior authorization may result in reduced benefits for non‑emergent services, but emergency services remain exempt from pre‑authorization reductions provided timely notification is given.
Exceptions: members do not need prior authorization to access in‑network OB/GYN practitioners for obstetrical or gynecological care though those practitioners may still need authorization for certain procedures; emergency services received from non‑network providers are covered without authorization pursuant to the No Surprises Act.
External review and expedited requests
Members may request external review within four months after the final internal appeal determination; standard external review decisions within 45 days; expedited external reviews for specified urgent circumstances (life‑threatening conditions, hospitalized members, prescription drug denials, IV infusions, denied step therapy exceptions) resolved within 72 hours; expedited external review may be requested concurrently with expedited internal appeal.
External review requests may be submitted via mail, fax or the designated online portal; vendor contact and submission addresses are provided in member materials.
Claims/cooperation: members and providers must furnish requested information and assistance for claims and appeals; failure to provide requested items may result in claim closure or denial.
Rehabilitation intensity threshold
Acute rehabilitation intensityAcute (intensive day) rehabilitation requires therapies provided three or more hours per day, five to seven days per week.
Rehab practitioner mixIntensive day rehabilitation involves two or more different therapy types provided by one or more licensed rehabilitation practitioners.
Inpatient rehabilitation triggerAn inpatient hospitalization is deemed for rehabilitation when the patient is medically stabilized and begins rehabilitation therapy.
Coverage effective timing thresholds
Standard effective dateRegular coverage effective date is the first of the month following plan selection (unless a special event specifies otherwise).
Birth/adoption/fosterCoverage for birth, adoption or foster placement is effective on the date of the event (newborns covered from time of birth).
Open enrollment exampleInitial open enrollment example: Nov 1, 2025 – Jan 15, 2026; enroll on or before Dec 15, 2025 → effective Jan 1, 2026.
Notification windowsNotify insurer of newborn/adopted child within 31 (up to 60) calendar days to avoid denial; additional premium rules apply (see contract).
Family out-of-pocket threshold
Family out‑of‑pocket maximumFamily maximum out‑of‑pocket amount equals two times the individual maximum out‑of‑pocket amount.
How family OOP is metFamily OOP may be satisfied by combination of eligible expenses from one or more family members; individual OOP cap still applies per member.
Reference locationIndividual and family OOP amounts are listed in the member's Schedule of Benefits.
Balance billing protection
Member responsibility under protectionsWhen balance‑billing protections apply (per No Surprises Act), the member is responsible only for the network‑equivalent cost share calculated as if services were from a network provider.
Protected services examplesProtections apply to emergency services, certain non‑emergency services at network facilities, and air ambulance services unless valid notice & consent applies.
Non‑protected billingNon‑network providers may balance bill for services not subject to protections; such balance billing may not count toward network OOP unless otherwise specified.
prosthetic reimbursement minimum
Prosthetic reimbursement floorProsthetic coverage and reimbursement reference Medicare/HCPCS guidance; coverage will be no less than 80% of the Medicare allowable as defined by CMS/HCPCS.
Covered prosthetic servicesIncludes purchase, fitting, adjustments, repairs and replacements when medically necessary (examples: LVAD as bridge to transplant, breast prosthesis after mastectomy).
Purchase vs rentalProsthetic devices should be purchased (not rented) when medically appropriate; applicable taxes, shipping and handling are covered.
LTACH ventilator duration threshold
LTACH ventilator duration criterionMechanical ventilation for 21 consecutive calendar days for six hours or more per day meets the ventilator criterion for LTACH consideration.
Weaning/ventilator contextLTACH candidates may include patients with failed weaning attempts at an acute care facility requiring extended ventilator support.
Authorization requirementLTACH benefits are subject to prior authorization as outlined in the contract.
Ventilator management monitoring frequency
Monitoring frequencyVentilator management requires assessments at least every four hours.
Stability thresholdsPatient should be hemodynamically stable, not vasopressor‑dependent, with PEEP ≤10 cm H2O and FiO2 ≤60% and SpO2 ≥90% as specified for LTACH candidacy.
pharmacy_quantity_limits
Refill restriction thresholdMedication refills are prohibited until a member's cumulative balance‑on‑hand is equal to or fewer than 15 days' supply.
Split‑fill ruleSplit‑fill program limits certain new therapies to 15‑day supplies for the first 90 calendar days (member pays half the 30‑day cost share for each 15‑day fill).
Extended days' supplySelect maintenance medications may be filled in extended supplies up to 90 calendar days through participating pharmacies or mail order.
Supply limits
General supply limitStandard limit is a 30‑day supply per prescription/refill; some maintenance drugs eligible for up to 90‑day supply via mail or participating retail.
Specialty drugsSpecialty and select drug categories are generally limited to 30‑day supplies when dispensed by retail or mail order.
Exclusions impactNon‑covered drug exclusions and managed‑drug limits (enumerated in contract) may further restrict supply/duration for specific medications.
Center of Excellence travel reimbursement maximum
Maximum per transplant serviceWhen travel/lodging benefits apply for a transplant at a Center of Excellence, maximum reimbursement is $10,000 per transplant service.
Minimum travel distanceCenter of Excellence travel/lodging benefits apply when member is required to travel more than 60 miles from residence to the Center of Excellence.
Documentation and timelineReceipts and required documentation must be submitted within six months of date of service to obtain reimbursement per member transplant reimbursement guidelines.
Prior Authorization Timeframes
Prior authorization timing summaryPrior authorization timing examples: at least 5 calendar days before elective inpatient admissions and home health start (except post‑discharge); at least 30 calendar days before initial transplant evaluation and clinical trial services; within 24 hours of any inpatient admission (including emergent).
Review decision timeframesUrgent pre‑service and concurrent urgent reviews decided within 24–72 hours; non‑urgent pre‑service reviews within 7 calendar days; retrospective/post‑service within 30 days.
Submission channelsPrior authorization requests must be received by phone, eFax, or provider web portal and meet the specified timing rules.
Emergency services outside U.S.
Coverage duration while abroadEmergency medical services incurred while traveling outside the U.S. are covered for up to 90 consecutive days.
Claim filing windowClaims for emergency services outside the U.S. must be submitted within 180 calendar days of service with clinical documentation in English (at member expense) and proof of travel.
Reimbursement to memberReimbursement for covered emergency services (less member cost‑share) is sent to the member, who is responsible for paying the provider; Explanation of Benefits details amounts.
Obtain authorization for continuation of care beyond clinical stabilization.
For post-stabilization balance-billing waiver, confirm the member can travel to a network facility or provide informed written consent and that all legal notice requirements were satisfied.
Billing Rule
Provider Notifications: Grace Period and Balance Billing
Providers will be notified when a member is in a premium grace period and claims for services rendered during the grace period may pend or be denied if premiums are unpaid. Providers should verify member eligibility and premium status prior to providing non-emergency services and be aware that balance billing protections may still apply where required by law.
There is a 60 calendar day grace period for premium payment; claims during this period may pend.
We will notify providers of the possibility of denied claims when the member is in the grace period.
Providers should confirm eligibility and prior authorization status for non-emergency services, especially for out-of-area care.
Prior Authorization
Prior Authorization — Fertility Preservation
Prior authorization may be required for fertility preservation services when iatrogenic infertility is a risk from medically necessary treatment. Covered services include evaluation, laboratory assessments, medications, treatments, and storage of gametes for up to one year. Providers should submit prior authorization requests as outlined in the Prior Authorization section.
Coverage applies when infertility is caused directly or indirectly by medically necessary treatment.
Storage of gametes covered up to one year; member is responsible for continued storage if coverage terminates.
Prior authorization may be required — contact the plan per authorization timelines.
Prior Authorization
Prior Authorization — Maternity
Providers do not need prior authorization for the act of delivery (obstetrical services) from an in-network obstetrician or gynecologist; however, certain maternity-related services and extended stays may require notification or prior authorization. An inpatient stay minimum of 48 hours for vaginal delivery and 96 hours for cesarean delivery is covered; notification to the plan is required. Other services related to maternity (prenatal/postpartum care, complications, hospital stays for medically necessary reasons, provider home visits, and certain testing) may require prior authorization as specified in the Schedule of Benefits.
No prior authorization required to obtain access to obstetrical/gynecological care from an in-network OB/GYN.
Notify the plan for inpatient stays; minimum coverage: 48 hours (vaginal), 96 hours (cesarean).
Prior authorization may be required for related services (prenatal/postpartum care, complications, home visits).
Prior Authorization
Prior Authorization — Assorted Services
Various services across the benefit package may require prior authorization. Examples include non-emergency air and ground ambulance transport, durable medical equipment, home health care, hospice, LTACH, certain dental anesthesia in facility settings, imaging and radiology services, transplant evaluations, clinical trials, and some rehabilitative services. Providers should consult the Schedule of Benefits and the Prior Authorization section for service-specific requirements.
Non-emergency air and ground ambulance transportation requires authorization.
DME, home health, hospice, LTACH, and many rehabilitative services may require prior authorization.
Clinical trial participation and transplant evaluations require prior authorization per stated timelines.
Imaging and advanced diagnostic testing may require prior authorization; two bills (technical and professional) may apply.
Prior Authorization
Prior Authorization Requirements and Timelines
Prior authorization requests (medical and behavioral health) must be submitted by telephone, eFax, or provider web portal and follow required timing: generally at least 5 calendar days prior to elective inpatient admissions or start of home health care (except post-discharge), within 24 hours of any inpatient admission, at least 30 calendar days prior to initial transplant evaluation or clinical trial services, and consistent with other specific service timelines. After receipt, decisions are communicated within regulatory timeframes: urgent concurrent reviews within 24–72 hours, urgent pre-service within 72 hours, non-urgent pre-service within 7 calendar days, and post-service retrospective within 30 calendar days. Timeframes may be extended if additional information is needed per law.
At least 5 calendar days prior to elective inpatient admission or start of most home health services.
Within 24 hours of any inpatient admission (including emergent inpatient admissions).
At least 30 calendar days prior to initial transplant evaluation and prior to clinical trial services.
Urgent pre-service: decision within 72 hours; non-urgent pre-service: within 7 calendar days; post-service: within 30 calendar days.
Denial Risk
Prior Authorization Requirements and Exceptions
Exceptions to prior authorization requirements exist: emergency services and access to in-network obstetrical/gynecological care do not require prior authorization. Prior authorization does not guarantee payment; authorizations are determinations of medical necessity/appropriateness and may be subject to retrospective review. Failure to obtain required prior authorization may result in reduced benefits, and network providers may not bill members for services they fail to authorize as required. In situations where additional information is needed, decision timeframes may be extended as permitted by law.
Emergency services are covered without prior authorization; however, post-stabilization and continuation of care require authorization.
Access to in-network OB/GYN care does not require prior authorization to obtain services from that provider, though certain OB services may still require authorization.
Prior authorization decisions are not guarantees of payment and may be subject to retrospective review.
Failure to obtain required prior authorization may reduce benefits; network providers cannot balance-bill members for lack of authorization.
Members have the right to access covered services and network providers and to be treated without discrimination based on protected characteristics.
Privacy and information rightsMembers have rights to privacy of PHI, access to medical records, notice of changes, and notification at least 60 days before changes to clinical review criteria take effect.
Member identification card
Issuance timingMember identification card is mailed after completed enrollment materials are received and initial premium payment is made.
Card contentsCard shows member name, member ID number, copayment amounts; deductible and out‑of‑pocket information accessible via the card/portal.
Temporary card optionA temporary member identification card can be downloaded from the Ambetter website if needed before the mailed card arrives.
Website / member portal
Primary online servicesAmbetter website provides provider search, member portal for claims/status/payments/ID card, formulary/PDL, PCP selection, and accumulator info.
Portal functionsSecure portal allows checking claim status, making payments, and obtaining a copy of the member identification card.
Where to accessWebsite accessible at AmbetterHealth.com for member resources, forms, and program details.
Balance billing & protections
No Surprises Act protectionsFederal No Surprises Act protections prohibit balance billing for covered emergency services, certain non‑emergency services at network facilities, and air ambulance services; member cost share is calculated as if service came from a network provider.
Notice & consent exceptionBalance billing protections may be waived only when valid notice and voluntary written consent are obtained per applicable law; many ancillary and emergency services are excluded from waiver.
Hospital ancillary ruleMembers cannot be balance billed for non‑emergency ancillary services (e.g., anesthesiology, radiology, pathology, neonatology) received at a network hospital.
Medically necessary
Medically necessary definitionMedically necessary means services consistent with symptoms/diagnosis, provided per accepted standards, not custodial or experimental, in the most cost‑effective setting, and of appropriate scope/duration/intensity.
Implication for coverageCharges for treatment not medically necessary are not eligible expenses under the contract.
Hospital confinement caveatFor hospital confinement, medically necessary means diagnosis/treatment cannot be safely provided as an outpatient.
Definitions (selected)
Non‑network providerA non‑network provider is not listed on the current network provider list; services from non‑network providers are not covered except as specifically stated (emergencies, certain services at network facilities, air ambulance, etc.).
Notice and consent overviewNotice and consent requires written notice in required format, timing (≥72 hours or ≥3 hours for short windows), voluntary written consent with specified content, and separate delivery and copy to member to waive protections.
Eligible expense rulesFor network providers eligible expense = contracted fee; for non‑network providers eligible expense depends on negotiated fee or plan‑determined reimbursement as required by law.
Cost sharing componentsCost sharing consists of deductible, copayments, and coinsurance; these components determine member financial responsibility per Schedule of Benefits.
Coinsurance treatmentCoinsurance is a percentage share of service cost; it applies toward the out‑of‑pocket maximum but not toward the deductible.
Copayment treatmentCopayments are fixed dollar amounts due at time of service; copays count toward out‑of‑pocket but not toward the deductible.
Effective Date
Regular effective date ruleCoverage is generally effective on the first day of the month following plan selection unless a special event specifies a different effective date.
Special events effective dateFor birth, adoption, or foster placement, coverage is effective on the date of the event; for marriage or loss of MEC, effective the first day of the following month.
Agency‑guided exceptionsErroneous enrollment, contract violation, or other exceptional circumstances use HHS guidelines to set an appropriate effective date (event date or regular effective date).
Third-Party Premium Payer
Permitted third‑party payersAcceptable third‑party premium payers per CMS guidance include: Ryan White HIV/AIDS program, Indian tribes/organizations, state/federal programs, certain tax‑exempt organizations, family members, employer ICHRA/QSEHRA arrangements, and qualifying private non‑profit foundations.
Payment expectationMembers are required to pay their premiums and third‑party payments are accepted only from the specified entities under the plan policy.
Balance billing protections summary
Summary of protectionsUnder federal law effective Jan 1, 2022, members are protected from balance billing for services subject to No Surprises Act protections and pay only the network‑equivalent cost share.
When protections applyProtections apply to emergency services, certain non‑emergency services at network facilities absent valid notice & consent, and air ambulance services.
Member action on suspected billingIf balance billed for a protected service, members should contact Member Services immediately using the number on their ID card.
Continuity of care / continuing care patient
Transitional continued care rightA member receiving ongoing treatment from a network provider who becomes non‑network may elect transitional continued care for the course of treatment for up to 90 calendar days after notice, or until no longer a continuing care patient.
Notification and election processThe plan will notify members of the provider termination and provide an opportunity to request transitional care under the stated time limits.
DME and Prosthetics
DME definition & rulesDurable medical equipment must withstand repeated use, serve a medical purpose, and be appropriate for home use; rental vs purchase rules apply (rental costs must not exceed purchase price).
Prosthetics coverageProsthetics include purchase, fitting, repair and replacement when medically necessary; devices should be purchased rather than rented when appropriate.
Authorization and limitsDME and certain rentals are subject to prior authorization and reasonable quantity limits; reimbursement limited to standard items when luxury features exceed medical necessity.
ABA (ASD)
ABA coverage scopeApplied Behavior Analysis (ABA) for Autism Spectrum Disorder is covered with no specified lifetime or visit limit but is subject to prior authorization to determine medical necessity.
Included servicesCoverage includes evaluation, ABA therapy, behavior training/management, habilitation, speech/OT/PT, psychiatric care, and medications/nutritional supplements for ASD.
iatrogenic infertility
Iatrogenic infertility definitionIatrogenic infertility is infertility caused by a medical intervention (including reactions from prescribed drugs or medical/surgical procedures, e.g., cancer treatment).
Fertility preservation linkMedically necessary fertility preservation services are covered when risk of iatrogenic infertility exists; prior authorization may be required.
Newborns' and Mothers' Health Protection Act rights
Federal minimum stay rightsUnder federal law, plans generally may not restrict hospital length of stay to less than 48 hours for vaginal delivery or 96 hours for cesarean; providers may discharge earlier after consulting the mother.
Authorization not requiredPlans/issuers may not require prior authorization for a provider‑prescribed length of stay up to the federal minimums.
Low-protein food products
Definition and eligibilityLow‑protein food products are specially formulated foods with <1 gram protein per serving for dietary treatment of specified inherited metabolic diseases and are provided under physician direction (excludes natural low‑protein foods).
Covered conditionsCovered for conditions such as PKU, MSUD, methylmalonic acidemia, isovaleric acidemia, propionic acidemia, glutaric acidemia, urea cycle defects and tyrosinemia.
Behavioral health medical necessity criteria
Clinical criteria sourcesBehavioral health determinations use Change Healthcare's InterQual criteria for mental health and ASAM criteria for substance use disorders.
Parity and settingsBehavioral health services are covered nondiscriminatorily; services should be provided in the least restrictive clinically appropriate setting.
Self-injectable drugs
What self‑injectables areSelf‑injectable drugs are medications delivered into muscle or under the skin with a syringe/needle that patients or caregivers can administer after initial instruction.
Coverage and cost shareSelf‑injectable drugs are covered under the prescription drug benefit and subject to applicable prescription drug cost share.
Pharmacy Lock-In program
Lock‑In program purposePharmacy Lock‑In program restricts pharmacy and/or prescriber choices for members meeting specific criteria to reduce overutilization and abuse.
Possible restrictionsRestrictions may include single network pharmacy, specific specialty pharmacy, or prescriber‑only fills for controlled substances; only fills at specified pharmacy/practitioner considered eligible covered expenses.
Appeal and notificationMembers/providers will be notified by mail of lock‑in decisions, duration, restrictions, and appeals rights; plan will review requests to change restrictions.
Transplant Service Expenses
Transplant services scopeTransplant benefits include pre‑transplant evaluation, harvesting, LVAD as bridge to transplant, pre‑transplant stabilization, transplant (including acquisition cost when authorized), post‑transplant follow‑up, donor search/testing and donor expenses as specified.
Authorization requirementPrior authorization must be obtained through the Center of Excellence, a network facility, or an approved non‑network facility before evaluation and related services.
Utilization review types
Utilization review typesUtilization review includes pre‑service/prior authorization review, concurrent review, and retrospective (post‑service) review.
PurposeThese reviews ensure medically necessary, appropriate, and efficient use of services; timeframes and submission channels are specified in prior authorization rules.
Prior Authorization
Prior authorization definedPrior authorization is a required approval from Ambetter to approve medical necessity or appropriateness for certain specialty or other services before the member receives them; authorizations are not guarantees of payment.
Submission requirementsRequests must be received by telephone, eFax, or provider web portal and meet the timing rules (e.g., ≥5 days before elective inpatient admission; ≥30 days for transplant evaluation/clinical trials; within 24 hours for inpatient admissions).
Reimbursement / Subrogation
Subrogation/reimbursement rightThe plan has reimbursement/subrogation rights and a lien on third‑party recoveries to the extent of benefits paid; member must reimburse the plan from any third‑party recovery.
Member cooperation obligationsMember must cooperate, notify plan of third‑party claims, include plan benefits in third‑party claims, and not settle without notice to preserve plan's rights.
Non-Assignment
Non‑assignment ruleCoverage, rights, privileges and benefits under this contract are not assignable; any attempted assignment is null and void.
Effect on providersProviders cannot rely on assignments from members to bind the plan to payment obligations outside the contract's terms.
No Third-Party Beneficiaries
No third‑party beneficiariesThis contract does not create or grant rights to third parties (e.g., providers); it is not intended to create third‑party beneficiary rights.
ImplicationProviders' rights and remedies arise only from their contract with the plan or applicable law, not from this member contract as third‑party beneficiaries.
Medicaid Reimbursement
Medicaid reimbursement practiceIf a member is eligible for state Medicaid, the plan will pay benefits to the state when proper proof of loss and notice of payment are received; plan payment limited to contract amount.
Satisfaction of obligationPayment to the state in good faith satisfies the plan's responsibility to the extent of that payment.
External Review
External review entitlementMembers may request an external review by an Independent Review Organization (IRO) after exhausting internal appeal rights (or in limited cases without completing internal appeal).
Standard/expedited timeframesStandard external review decision provided no later than 45 days after request; expedited decisions no later than 72 hours for urgent cases meeting criteria.
Filing windowRequest for external review must be made within four months after the date of the final internal appeal determination notice.
Complaint
Complaint definitionA complaint is any member communication (oral, written, electronic) expressing dissatisfaction with the health plan or its providers, including service availability, quality of care, or administrative issues.
Filing and resolutionMembers should contact Member Services for questions/concerns; formal complaints acknowledged within 5 business days and resolved within 30 calendar days (with possible 14‑day extension).
Information requiredComplaints should include member name, ID, contact info, detailed description and supporting documentation; submission methods include phone, mail, fax, or grievance/appeal form.