CurrentCentene | Ambetter Health (Celtic Insurance Company)Policy AMB24-IN-C-00014
2025 Evidence of Coverage — Individual Member Contract (Ambetter Health)
This document is the Ambetter Health individual member contract (Evidence of Coverage) describing covered services, member rights/responsibilities, network access, prior authorization notice, and administrative procedures for members under Celtic Insurance Company/Ambetter Health.
Policy Summary
PayerCentene / Ambetter Health (Celtic Insurance Company)
PolicyEvidence of Coverage / Individual Member Contract — 2025
Policy CodePolicy AMB24-IN-C-00014
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for specified non-emergency services (submit via phone, fax, or provider web portal; urgent reviews within 48 hours).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
10 daysRight to return contract
1-833-543-3145Member Services
31 daysNotice before changes
60 dayPremium grace period
24/7Nurse Advice Line
Covered Services, Limits, and Exclusions
Coverage and administrative criteria from excerpt
Covered services, limits, and administrative rules. All covered services must be medically necessary and not experimental or investigational; some services require prior authorization. Essential health benefits are included as defined by law.
Covered services include 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, chronic disease management, and pediatric services including oral and vision care. Essential health benefits are not subject to lifetime or annual dollar maximums.
Medical and surgical benefits include physician services, pre- and post-surgical procedures and testing, clinical laboratory tests, imaging (X-ray, MRI, CT, PET), genetic and molecular testing when medically necessary, chemotherapy (including oral), inhalation/infusion/radiation therapy, anesthesia and related drugs, and telehealth services (subject to same cost sharing as in-person when not through Virtual 24/7).
Medically necessary reconstructive surgery (including post-mastectomy reconstruction and lymphedema treatment related to mastectomy) and certain dental surgery-related anesthesia are covered per criteria; dental anesthesia in hospital/ASC settings for children <19 or those with significant medical/behavioral conditions is covered with authorization where required.
Air Ambulance Coverage Criteria
Air ambulance services coverage, limitations, and balance-billing protections.
Covered when transporting a member experiencing an emergency condition to the nearest appropriate hospital; neonatal transport to the nearest neonatal special care unit; interfacility transport when authorized; and when required by the plan to move a member from a non-network to a network provider.
Emergency air ambulance services do not require prior authorization; non-emergency air ambulance services require prior authorization.
Balance billing protections: under federal law (No Surprises Act) air ambulance services provided by non-network providers that are subject to surprise billing protections cannot balance bill the member; member cost share is calculated as if services were provided by a network provider and based on the recognized amount defined by law.
Limitations and exclusions: benefits limited to situations where ground ambulance cannot reach the location, services requested by police/medical authorities at an emergency site, and other plan-specified limits. No benefits for air ambulance services covered by local governmental/municipal bodies unless required by law, for non-emergency air ambulance without authorization, for air transport outside the 50 United States/DC (with limited exceptions), for transport solely for member comfort or convenience, or non-emergency commercial air travel.
Ground/Water Ambulance Coverage Criteria
Ground and water ambulance coverage, prior authorization rules, and balance-billing notes.
Covered when transporting a member with an emergency condition to the nearest appropriate hospital; neonatal transport to nearest neonatal special care unit; interfacility transport or transport to a more appropriate level of care when authorized; when ordered by employer/school/public safety official and member cannot refuse; and when required by the plan to move a member from a non-network provider to a network provider.
Prior authorization is not required for emergency ambulance transportation. Non-emergency ambulance transportation requires prior authorization.
Balance billing note: unless otherwise required by federal or state law, non-network ambulance providers may balance bill the member for non-covered amounts; balance billing protections may apply in certain circumstances under federal law.
DME, Supplies, and Orthotics Coverage Criteria
Durable medical equipment (DME), medical/surgical supplies, orthotics, and prosthetics coverage, repair/replacement rules, and prior authorization requirements.
DME is covered when prescribed by a physician and is primarily and customarily used to serve a medical purpose; rental or purchase is allowed and the plan may authorize purchase when cost-effective. Delivery and installation costs are covered; related supplies are covered when included in rental or when equipment is owned by the member.
Repairs, adjustments, and replacements are covered when continued use is medically necessary and there is reasonable justification (warranty expiration alone is not sufficient). Replacements allowed when item is worn out, damaged beyond repair, or individual needs change (e.g., growth, weight change). Repair/replacement exclusions include loss/theft and damage due to misuse or neglect.
All types of DME and supplies are subject to prior authorization as outlined in the policy.
Orthotic devices: coverage includes initial purchase and repair of custom rigid or semi-rigid supportive devices, with casting, molding, fittings, and adjustments included. Examples: cervical collars, ankle-foot orthoses, splints, corsets, trusses, wristlets, slings, built-up shoes, custom shoe inserts, gradient compression garments, and positional plagiocephaly devices. Orthotic appliances may be replaced once per year when medically necessary; additional replacements allowed when medically necessary or if damaged beyond repair.
Prosthetics: covered for artificial substitutes for missing body parts and their adjoining tissues; includes purchase, fitting, adjustment, repairs and replacements when medically necessary. Prosthetic devices should be purchased (not rented) when appropriate; taxes, shipping and handling covered. Covered examples include LVADs as bridge to transplant, internal heart valves, pacemakers, intraocular lenses, artificial limbs, ostomy supplies, wigs (one per year when through network), and restoration prostheses. Exclusions include dentures and dental appliances, certain non-rigid appliances, wigs purchased through non-network providers (except as noted), and penile prostheses when not medically necessary or cosmetic.
Operational note: plan may establish quantity limits and require authorization for certain items (see Schedule of Benefits for limits).
Autism Spectrum Disorder Coverage
Autism Spectrum Disorder (ASD) benefits and Applied Behavior Analysis (ABA).
Coverage provided for ASD when prescribed by a physician or behavioral health practitioner and may include evaluation/assessment, applied behavior analysis (ABA) therapy, speech therapy, occupational therapy, physical therapy, behavior training/management, psychiatric care (counseling by licensed providers), and medications or nutritional supplements to address ASD symptoms.
No limitation exists within the benefits for ABA services; ABA services are subject to prior authorization to determine medical necessity. If multiple services are provided on the same day by different providers, separate cost shares may apply to each provider.
Clinical Trial Coverage
Clinical trial coverage rules, eligible trials, and requirements.
Routine patient care costs incurred as a result of participation in an approved clinical trial for detection or treatment of cancer or other life-threatening disease or condition are covered when services would otherwise be covered under the plan.
Covered routine costs include medically necessary services to administer or use the device or drug under evaluation, and drugs/devices approved for sale by the FDA (regardless of indication). Items and services provided solely for data collection or those investigational items themselves are excluded. Items customarily provided by research sponsors free of charge are excluded.
Eligibility requirements vary by phase: Phase I/II trials must be sanctioned by NIH/NCI and conducted at appropriate centers; Phase III/IV trials must be approved or funded by listed federal agencies or accredited entities. The treating facility and personnel must have appropriate expertise and volume. Providers must obtain informed consent consistent with legal and ethical standards. Participation in clinical trials is subject to prior authorization as outlined in the policy.
Colorectal Cancer Screening and Preventive Care
Preventive care coverage including colorectal cancer screening.
Preventive services are covered per USPSTF, ACIP (immunizations), and HRSA guidelines and as required by the Affordable Care Act and applicable state law. Preventive services obtained from network providers are covered without member cost share when applicable.
Colorectal cancer screening: covered for non-symptomatic members in accordance with current USPSTF guidelines, including members age 45 and older or younger than 45 if at high risk.
Preventive care updates: new USPSTF/CDC/HRSA recommendations become effective per regulatory timing; Ambetter's Preventive Services Guide is updated annually and available online.
Diabetic Care and Dialysis Coverage
Diabetic care and dialysis services coverage.
Diabetic care: benefits for medically necessary services and supplies for gestational, type I and type II diabetes when prescribed by a provider, including routine foot care (trimming nails, corns), podiatric exams, laboratory and radiological testing, orthotics and diabetic shoes, self-management equipment and supplies (glucose monitors, strips, syringes/needles), urinary protein/microalbumin and lipid profiles, eye exams, educational/nutritional counseling, retinopathy screening, and prescription medications. State and federal limits on insulin out-of-pocket maximums apply.
Dialysis: medically necessary acute and chronic dialysis (hemodialysis and peritoneal dialysis) covered when criteria met; services covered in outpatient dialysis facilities, home dialysis (with training), and hospital settings. Covered services include processing and administration of blood/blood components related to dialysis. Home dialysis equipment and supplies covered to standard items meeting medical needs; plan may determine rental vs purchase and may authorize purchase if cost-effective; purchase must be from an authorized provider.
Care Management Programs
Care management program overview and services.
Care management is a program where a registered nurse or licensed mental health professional assists members through assessment, planning, implementation, coordination, monitoring and evaluation of care and benefits. Care managers help members coordinate services, locate community resources, and work with the member's physician to develop individualized care plans for complex medical or behavioral health needs.
Care management is instituted at the plan's option and when mutually agreed; members who think they could benefit should contact Member Services to request assessment and referral to a care manager.
LTACH — Level of Care and Respiratory Criteria
Long Term Acute Care Hospital (LTACH) coverage criteria and respiratory thresholds.
LTACH coverage is for medically necessary post-acute complex care when needs cannot be met in a rehabilitation or skilled nursing facility and the patient can participate in goal-oriented rehabilitation or has medical complexity requiring acute care.
Clinical examples and criteria include complex wound care (frequent complicated dressing changes, debridement), infectious disease requiring parenteral anti-infectives, multi-comorbidity care, rehabilitation needs, failed weaning attempts, and mechanical ventilator support where patient has received mechanical ventilation for 21 consecutive days for six hours or more per day and exhibits weaning potential.
Respiratory-specific thresholds: patient must be hemodynamically stable and not vasopressor-dependent; maximum PEEP requirement <= 10 cm H2O and FiO2 <= 60% with O2 saturation >= 90% as part of stability criteria for LTACH transfer.
Lymphedema
Lymphedema treatment coverage summary.
Lymphedema treatment is covered when rendered or prescribed by a licensed physician or provided in an authorized facility. Coverage includes multilayer compression bandaging systems, custom or standard-fit gradient compression garments, and related therapeutic supplies as medically necessary.
Family Planning, Infertility, Habilitation & Rehabilitation
Family planning, infertility diagnostic coverage, and habilitation/rehabilitation services.
Family planning/contraception: the full range of FDA-identified contraceptives and associated services (screening, education, provision, counseling, follow-up, and management including insertion/removal) are covered under preventive care without cost sharing when provided by a network provider and legal under applicable law. Services integral to furnishing contraceptives (e.g., anesthesia for sterilization) are included.
Infertility services: coverage limited to medically necessary diagnostic tests to determine infertility and treatment of underlying medical conditions causing infertility (e.g., endometriosis); exclusions apply for artificial insemination, IVF, embryo transplant, GIFT, and ZIFT.
Habilitation and rehabilitation: covered when medically necessary, including inpatient and outpatient physical, occupational, speech, respiratory and cardiac therapy, neurocognitive and cognitive rehabilitation for acquired brain injury, and confinement in approved extended care facilities subject to limits. Services cease to be rehabilitation when member has reached maximum therapeutic benefit, no measurable progress toward goals, or care becomes custodial.
Mammography Screening
Mammography screening intervals.
Routine screening mammography: one baseline screening between ages 35–40. For members under 40 at risk, screening intervals as clinically indicated. For members aged 40 and older, annual screening mammography is covered and additional views as required for proper evaluation.
Maternity and Newborn
Maternity and newborn coverage and minimum inpatient stays.
Maternity care: inpatient stay for mother and newborn covered for minimum 48 hours after vaginal delivery and 96 hours after cesarean section. Provider may discharge earlier after consultation; plan does not require authorization for stays up to those minimums. Some maternity-related services may require prior authorization (see Schedule of Benefits).
Newborn coverage: eligible newborns are covered from birth until the 31st day after birth; to continue coverage beyond 31 days, additional premium and notification are required within specified timeframes. Adopted children placed for adoption are covered from date of placement until 31 days after placement with similar continuation requirements. Newborn and mothers' health protections per federal law apply regarding length of stay.
Hospital and Emergency Services
Hospital and emergency services coverage rules and post-stabilization care.
Hospital benefits include daily room & board up to semiprivate room rate, private room when medically necessary, ICU, operating/recovery room use, outpatient surgical facility services, routine inpatient drugs/supplies, and outpatient surgery facility use.
Emergency services: covered 24/7 both in and out of service area; benefits include facility costs, physician services, supplies and prescription drugs charged by the facility. Emergency services do not require prior authorization. Services to stabilize an emergency condition are covered; follow-up care is not considered emergency care. Post-stabilization care is not emergency services and may require authorization; continuation beyond stabilization is covered only if authorized and medically necessary.
Balance billing protections: certain emergency and post-stabilization services are protected from balance billing under federal law; members are responsible only for applicable in-network cost share when protections apply.
Medical Foods and Donor Human Milk
Medical foods and donor human milk coverage and exclusions.
Medical foods: covered for outpatient total parenteral nutrition, outpatient elemental formulas for malabsorption, and dietary formula medically necessary for treatment of PKU and certain inborn errors of metabolism.
Donor human milk: pasteurized donor human milk is covered when prescribed by a pediatrician or licensed pediatric provider stating the infant is medically or physically unable to receive maternal milk or the mother is unable to produce sufficient milk.
Exclusions: other dietary formulas, food thickeners, oral nutritional supplements, special diets, prepared foods/meals, and formulas for access problems are excluded unless specifically stated.
Medical Vision Services
Medical vision services scope and exclusions.
Covered medical vision services include vision screenings to diagnose or detect disease or refractive error. Vision services under the medical contract exclude routine refractive services such as eye exams for employment, refractions for presbyopia, radial keratotomy/LASIK/refractive surgery, orthoptics/vision training/subnormal vision aids, and services/materials provided under workers' compensation or required by governmental agencies.
Post-cataract: one pair of eyeglasses or contact lenses per member following covered cataract surgery is covered (see Outpatient Medical Supplies).
Behavioral Health and Substance Use Disorder Benefits
Behavioral health, mental health and substance use disorder (MH/SUD) benefits, levels of care, and parity.
MH/SUD benefits are provided inpatient and outpatient, complying with parity laws. Members may choose any provider in the behavioral health network.
Inpatient covered services include inpatient psychiatric hospitalization, inpatient detoxification, crisis stabilization, inpatient rehabilitation, residential treatment facilities, and electroconvulsive therapy (ECT).
Outpatient covered services include partial hospitalization (PHP), intensive outpatient (IOP), medication management, psychological and neuropsychological testing, outpatient detox programs, assessment/evaluation, telehealth therapy and medication monitoring, applied behavior analysis (ABA) when indicated, individual/group therapy, medication-assisted treatment (MAT), transcranial magnetic stimulation (TMS), and ECT when medically necessary.
Utilization management uses InterQual for mental health and ASAM criteria for SUD determinations. Services should be delivered in the least restrictive clinically appropriate setting. Some services may require prior authorization; emergent inpatient withdrawal management and emergent inpatient treatment do not require prior authorization. Integrated Care Management available for behavioral health needs.
Outpatient Medical Supplies
Outpatient medical supplies benefit highlights.
Covers miscellaneous outpatient medical supplies including prosthetic eyes or larynx, basic artificial limbs, ostomy supplies, one pair of eyeglasses or contact lenses following covered cataract surgery, rental of one CPM machine after covered joint surgery, wheelchair cushions, ventilators, and infusion therapy supplies.
Coverage limits: one pair of foot orthotics per year per member (pair), and other items subject to plan limits; see Schedule of Benefits for specifics.
Prescription Drug Expense Benefits and Drug Exception Processes
Prescription drug benefits, formulary rules, exception and step-therapy processes, and supply limits.
Prescription drug coverage applies to prescriptions from licensed network pharmacies; includes oral anticancer medications and drugs dispensed per state law. Covered drugs should be recognized in standard reference compendia or meet off-label criteria when supported by clinical evidence.
Formulary: a preferred generic-first approach; formulary is maintained and updated periodically. Not all strengths/forms may be covered; plan-specific designs may exclude categories. Extended days' supply (up to 90 days) available for select maintenance medications through participating pharmacies.
Non-covered drug categories include weight-loss drugs (unless on formulary), certain institutional-dispensed meds, refills beyond allowed periods, OTC equivalents when not on formulary, experimental/ investigational drugs, and foreign prescriptions (except emergency while traveling).
Exception and step therapy: members or prescribers may request standard or expedited exceptions; expedited review within 24 hours for exigent circumstances. Protocol exceptions for step therapy granted when a preceding drug is contraindicated, expected ineffective, previously tried and failed, or causes harm; denials must be accompanied by clinical rationale. External review available for exception denials.
Drug Exception and Transplant Coverage Criteria
Transplant coverage overview and administrative requirements.
Transplant services are covered when member is accepted as a transplant candidate and preauthorized; prior authorization through designated Center of Excellence is required before evaluation and related services. Additional testing/treatment or stabilization may be required to determine medical necessity.
Covered transplant-related services include pre-transplant evaluation and harvesting, LVAD as a bridge to transplant when authorized, outpatient services related to transplant (e.g., high-dose chemotherapy, stem cell collection), acquisition cost for organ or bone marrow when authorized and performed at participating facility, pre- and post-transplant care, and donor costs when recipient's policy covers donor (subject to limits). Travel, lodging and food reimbursement may be separately limited per Member Transplant Travel Reimbursement Policy.
Preventive Care
Preventive care summary and application.
Preventive services covered per USPSTF 'A' or 'B' recommendations, ACIP immunization recommendations, and HRSA guidelines for women and for infants/children; network-provided preventive services are covered without member cost share when applicable.
Preventive services follow regulatory timelines for inclusion of new recommendations; plan provides an annual Preventive Services Guide online and complies with applicable state law.
General Non-Covered Services and Exclusions
General non-covered services, exclusions, and notable limitations.
Services not covered include those provided prior to effective date or after termination, services in excess of eligible expense, weight modification or bariatric surgery except as specified, reversal of sterilization, weight loss programs/gym memberships/exercise equipment, most cosmetic treatments (except medically necessary reconstructive surgery), most vocational/educational services, routine or elective care outside service area, non-covered dental services (except where specified), hearing aids except as provided, and many other enumerated exclusions.
Specific non-covered items include surrogacy-related services and expenses, in vitro fertilization and related procedures, alternative treatments (acupressure, aromatherapy, massage, etc.) except as specified, frozen gamete/embryo use for surrogacy, and recreational or medicinal cannabis.
Prescription and pharmacy exclusions include drugs for members enrolled in Medicare Part D (as specified), foreign prescriptions except emergency, weight-loss drugs unless on formulary, compounded drugs lacking an FDA ingredient, and other formulary-specified exclusions. See full exclusions list for details.
Non-Network Services and Balance Billing Protections
Non-network services, provider directory, and balance billing protections.
Generally services from non-network providers are not covered except when balance billing protections apply or when covered services are unavailable from a network provider within a reasonable distance and prior authorization is obtained.
Provider directory is available online (Find a Doctor) and by request at no charge from Member Services; the plan will respond to inquiries about network status within one business day. Members may designate a PCP and Member Services can assist with appointments.
If member receives services from a non-network provider due to inaccurate directory information or in response to a network status inquiry, and the services are covered, member will only owe in-network cost sharing and will not be balance billed.
Under federal No Surprises Act protections effective Jan 1, 2022, members cannot be balance billed for emergency services, certain non-emergency services at network facilities by non-network providers unless member consents after notice, and for air ambulance services subject to the Act. In such cases member cost share is calculated as if services were from a network provider and based on the recognized amount per law. If balance billed inappropriately, members should contact Member Services immediately.
Contract Lifecycle Rules
Contract lifecycle rules: termination, cancellation, reinstatement, discontinuance, and refunds.
Termination events include non-payment of premiums (subject to grace period), receipt of a request to terminate, death (for individual plans), insurer non-renewal/decline to renew, covered child exceeding limiting age, and loss of eligibility. All coverage ceases on termination.
Refund upon cancellation: unearned premium will be refunded promptly (within 20 calendar days) when contract is cancelled by member; cancellation effective upon receipt or later specified date.
Reinstatement: plan will reinstate a contract erroneously terminated or cancelled, resulting in restoration of enrollment with no break in coverage.
Discontinuance: if insurer discontinues offering contracts, written notices provided per regulatory timelines (90-day or 180-day notices) and guaranteed issue options may be offered per state requirements.
Subrogation and Reimbursement
Subrogation and right of reimbursement policies and member obligations.
Ambetter Health has subrogation and reimbursement rights when benefits are provided for injuries or illness caused by third parties. The plan may recover full cost of benefits from recoveries obtained by or on behalf of the member (including settlements, judgments, uninsured/underinsured motorist payments, workers' compensation, medical payments coverage, etc.).
By accepting benefits, the member acknowledges subrogation and reimbursement rights and assigns proceeds of recovery to the plan to the extent of benefits paid. The member must cooperate, notify the plan of claims or lawsuits, include the plan's benefit amount in any claim against third parties, and not settle claims without notifying the plan.
Ambetter Health may assert liens, intervene in suits, and take actions to protect recovery rights; members are required to reimburse the plan from recoveries as first priority. Failure to cooperate may render the member responsible for repayment plus costs and attorney fees incurred in recovery.
Coordination of Benefits Rules
Coordination of Benefits (COB) rules and definitions.
COB applies when a member is covered by two or more health benefit plans to determine primary vs secondary payment obligations. Ambetter follows NAIC guidelines and applicable federal/state regulations.
Definitions: Plan includes group/non-group insurance, closed panel plans, certain government benefits (as permitted), and other specified arrangements; Plan excludes accident-only, hospital indemnity, specified disease, long-term care non-medical benefits, and Medicare supplement policies.
Order of benefit determination rules cover dependent child situations, active vs retired employees, COBRA/state continuation, and length of coverage. When Ambetter is secondary, benefits are reduced so total payments do not exceed Ambetter's allowable benefit; payments will not exceed what Ambetter would have paid as primary.
Allowable expense defined as necessary, reasonable, customary expense covered by any plan involved. Ambetter may exchange necessary information with other organizations to determine COB and benefits payable.
Claims, Proof of Loss, and Appeal/External Review Processes
Claims, proof of loss, appeals, expedited/internal/external review processes, and member rights.
Claims: notice of claim must be provided within 30 calendar days of loss or as soon as reasonably possible. Claim forms furnished within 15 days after notice.
Proof of loss: written proof must be provided within 90 calendar days of loss or as soon as reasonably possible; proofs later than one year may be denied unless legally incapacitated.
Appeals: members have 180 calendar days to file an internal appeal of adverse benefit determinations; plan will acknowledge within five business days and decide within 30 calendar days (with possible 14-day extension). Expedited appeals (serious jeopardy or severe pain) resolved within 48 hours.
External review: if dissatisfied with internal appeal outcome, members may request external review by an Independent Review Organization (IRO) within specified timeframes; expedited external review available for urgent cases. External review decisions are binding on the plan and the plan will cover IRO costs. Members have rights to access documents, receive notices of decisions, and be assisted with filing external review requests.
Foreign Emergency Care Reimbursement
Foreign emergency care reimbursement rules.
Emergency services incurred outside the United States are covered for up to 90 consecutive days from start of travel; beyond 90 days no benefits for the travel period are provided. Members must submit foreign claims in English (or with English translation) within 180 calendar days and include medical records and proof of payments at member's expense.
Reimbursement amount based on member's benefit plan and eligibility on date of service, member cost share at date of service, and currency exchange rates at time of transaction. If services qualify as true emergency services, member will be reimbursed minus applicable member cost share.
Medicaid Reimbursement Interactions
Medicaid interactions and reimbursement rules.
Amount payable under this contract will not be changed due to a member's eligibility for Medicaid. Ambetter will pay benefits to the state if the state provides proof of payment for covered services and such payment will satisfy Ambetter's responsibility to the extent of that payment.
Payments to the state are limited to amounts payable under this contract for covered services for which reimbursement is due.
Member Privacy, Language Access, and Auxiliary Services
Member privacy, language access, and auxiliary services rights.
Personal Health Information (PHI): the plan protects oral, written, and electronic PHI in accordance with HIPAA and provides a Notice of Privacy Practices; members may request the complete notice online or via Member Services.
Language access and auxiliary aids: members not proficient in English have the right to free, timely help and information in their language; members with auditory/visual conditions have the right to auxiliary aids/services at no cost. To request translation or auxiliary services, contact Member Services (provided phone/TTY numbers).
Multilingual notices and contact information are provided; plan materials include translations and resources to request assistance.
Prior Authorization, Billing, and Provider Responsibilities
Prior Authorization
Prior Authorization Notice
Prior Authorization Notice: Certain services and supplies require prior authorization. Authorizations are decisions by Ambetter Health to approve medically necessary specialty or other care but do not guarantee payment. Providers must obtain authorization for services listed on the Schedule of Benefits or when care is provided by a non‑network provider, when admitted to a network facility by a non‑network provider, or when referred by a non‑network provider. Failure to obtain required prior authorization may result in denied benefits; network providers may not bill members for a provider's failure to obtain prior authorization.
- Authorizations approve medical necessity but are not guarantees of payment.
- Obtain authorization as shown on the Schedule of Benefits before services are provided when required.
- Network providers cannot bill members for their failure to obtain required prior authorization; non‑network providers may balance bill if authorization is not obtained.
Note
Emergency Services Prior Authorization Exception
Emergency Services Prior Authorization Exception: Emergency services are covered without prior authorization. If admitted as an inpatient following emergency care, notify Ambetter within 48 hours or as soon as reasonably possible so inpatient setting and medically necessary days can be reviewed and authorized. Continuation of care beyond stabilization requires authorization to be covered.
- Emergency services (in or out of area) do not require prior authorization.
- Notify Ambetter within 48 hours (or as soon as reasonably possible) after an emergency admission for inpatient authorization review.
- Continuation of care after stabilization is not emergency care and requires authorization to be covered.
Note
Authorization Definition
Authorization Definition and Scope: "Prior authorization" means a decision to approve specialty or other medically necessary care for a member. Requests may be initiated by the member's PCP or provider group and are subject to utilization review (pre‑service, concurrent, or retrospective). Authorization approval indicates that the service meets medical necessity criteria but does not constitute a guarantee of payment.
- Authorizations may be pre‑service, concurrent, or retrospective.
- An approval documents medical necessity determinations but is not a payment guarantee.
Prior Authorization
Inpatient Notification and Authorization
Inpatient Notification and Authorization: If a member is an inpatient on their effective date and prior coverage continues, services remain under prior coverage until discharge. Otherwise, Ambetter coverage applies but the member or provider must notify Ambetter within two days of the effective date so services can be reviewed and authorized. For all inpatient admissions (including emergent), providers must submit notification/authorization within 24 hours of admission.
- Notify Ambetter within two days of the member's effective date for ongoing inpatient care when prior coverage has ended.
- Prior authorization/notification for inpatient admissions must be provided within 24 hours of any inpatient admission, including emergent admissions.
Note
Grace Period Provider Notification
Grace Period Provider Notification: During the 60‑day premium grace period (for members not receiving a premium subsidy), the contract remains in force but claims for services rendered may pend. Ambetter will notify members and providers of non‑payment and the possibility of denied claims if premiums are not paid. Providers should be aware services during the grace period may be denied if premium obligations are not satisfied.
- There is a 60‑day grace period for non‑subsidy members; coverage continues but claims may pend.
- Ambetter will notify providers of the potential for denied claims during the grace period.
Prior Authorization
Prior Authorization for Non‑Emergency Transport and Out‑of‑Area Non‑Emergency Services
Prior Authorization for Non‑Emergency Transport and Out‑of‑Area Non‑Emergency Services: Non‑emergency air, ground, and water ambulance services require prior authorization. Non‑emergency air ambulance specifically requires authorization; emergency air ambulance does not. When members receive non‑emergency services outside the Indiana service area, authorization may be required — contact Member Services. Balance billing protections vary by service and law.
- Non‑emergency air ambulance requires prior authorization; emergency air ambulance is covered without prior authorization.
- Non‑emergency ground and water ambulance transportation requires prior authorization.
- Out‑of‑area non‑emergency services may require authorization; contact Member Services for prior authorization requirements when traveling outside the service area.
Note
Emergency Services Coverage and Balance Billing Note
Emergency Services Coverage and Balance Billing Note: Emergency services are covered 24/7 in and out of the service area without prior authorization. Some emergency providers may be out‑of‑network; federal and state balance billing protections may apply and non‑network emergency providers may not balance bill members for covered emergency services where protections apply.
- Emergency services covered in and out of service area without prior authorization.
- Balance billing protections may prevent non‑network emergency providers from billing members beyond applicable cost sharing.
- Providers should check applicable state or federal laws for balance billing rules.
Prior Authorization
Expedited Exception Request
Expedited Exception Requests (Drugs/Step Therapy): Members, designees, or prescribing physicians may request an expedited review for exigent circumstances (serious jeopardy to life/health or inability to regain maximum function, severe unmanaged pain, or ongoing course of non‑formulary treatment). Expedited exception determinations will be provided promptly (24 hours for drug exceptions) and, if granted, coverage will be provided for the duration of the exigency.
- Expedited exception available when exigent circumstances threaten life, health, or function or for ongoing non‑formulary treatment.
- Decision timelines: expedited drug exception decisions provided within 24 hours of request receipt.
- If granted, coverage of the non‑formulary drug or protocol exception is provided for the duration of the exigency.
Note
External Exception Request Review
External Exception Request Review: If an exception request is denied, the member, designee, or prescribing physician may request an external review by an independent review organization (IRO). For standard exception denials, Ambetter will notify the decision on the external exception review within three business days; for expedited exception denials, within one business day. If the external review is granted, coverage will be provided as specified (duration of prescription or exigency).
- External review timelines: standard external exception review decision within three business days; expedited within one business day.
- If external review grants the exception, coverage is provided for the duration of the prescription or exigency.
Prior Authorization
Imaging Prior Authorization
Imaging Prior Authorization: Medically necessary radiology and diagnostic imaging (e.g., X‑ray, MRI, CT, PET/SPECT, mammogram, ultrasound) are covered services but may require prior authorization per the Schedule of Benefits. Note that technical and professional components may be billed separately and both may be subject to cost sharing. Non‑network providers should not balance bill members beyond applicable cost sharing when balance billing protections apply.
- Check the Schedule of Benefits for which imaging services require prior authorization.
- Two bills may be issued for imaging (technical and professional components); both may carry cost sharing.
- Non‑network imaging providers must respect balance billing protections when applicable.
Denial Risk
Non‑Covered Services and Exclusions
Non‑Covered Services and Exclusions: The contract lists specific exclusions and non‑covered services (e.g., certain alternative therapies, equipment, and services listed in the General Non‑Covered Services and Exclusions). Providers should review the contract exclusions and the Schedule of Benefits; services excluded from coverage cannot be authorized or paid under the contract.
- Review the General Non‑Covered Services and Exclusions for items not payable under the contract.
- All types of durable medical equipment and supplies are subject to prior authorization but certain equipment/items may be excluded from coverage.
Documentation Required
Cooperation and Authorizations
Cooperation and Authorizations (Member/Provider Responsibilities): Members and providers must cooperate with Ambetter's requests, including signing and delivering authorizations for Ambetter to obtain medical records and other information. Failure to provide requested information or to cooperate may result in claim closure or denial. Providers must submit prior authorization requests via telephone, fax, or provider web portal and follow required timelines.
- Members must sign, date, and provide authorizations permitting Ambetter to obtain relevant records.
- Failure to provide requested information may result in claims being closed or denied.
- Prior authorization requests must be submitted by telephone, fax, or provider web portal and meet the timelines in the policy.
Note
PHI Privacy and Notice
Personal Health Information (PHI) Privacy and Notice: Ambetter Health protects oral, written, and electronic PHI in accordance with HIPAA and maintains a Notice of Privacy Practices. The Notice describes how PHI may be used/disclosed and how members can access their information. Providers and members may obtain the complete notice online or via Member Services.
- Ambetter follows HIPAA requirements and issues an annual Notice of Privacy Practices.
- Visit ambetterhealth.com/privacy-policy.html or contact Member Services for the full Notice and questions about PHI.
- Providers must handle PHI consistent with HIPAA and the member's privacy rights.
Codes, Thresholds, and Quick Numeric Rules
Durable medical equipment and prostheticsmixedCovered
| Orthotic devices: initial purchase, repair, casting, molding, fittings, adjustments; applicable tax/shipping/postage/handling charges covered; covered examples include cervical collars, ankle foot orthosis, splints, corsets, trusses, wristlets, slings, built-up shoes, devices for positional plagiocephaly, custom made shoe inserts, orthopedic shoes, standard elastic stockings; orthotic appliances may be replaced once per year when medically necessary; additional replacements allowed when medically necessary or irreparably damaged. | |
| Prosthetic devices: purchase, fitting, adjustments, repairs and replacements of prosthetic devices that replace or restore function of missing or malfunctioning body parts; examples include LVAD (when used as bridge to transplant), internal heart valves, pacemakers, artificial limbs and eyes, colostomy/ostomy supplies, restoration facial prosthesis, cochlear implants, custom breast prosthesis (with additional allowances), wigs up to one per calendar year when purchased through a network provider; taxes/shipping included. |
Diagnostic and genetic testing (narrative list)mixed
| Medically necessary genetic and molecular cancer testing and related diagnostic services (e.g., tumor mutation testing, next generation sequencing, hereditary germline mutation testing, pharmacogenomics testing, whole exome and genome sequencing) when supported by labeled FDA indications, CMS national coverage determinations, nationally recognized clinical practice guidelines or consensus statements, local Medicare administrative contractor determinations, or peer-reviewed evidence. |
Formulary referencesmixed
| Formulary / Prescription Drug List references: American Hospital Formulary Service (AHFS) Drug Information, American Medical Association Drug Evaluation, United States Pharmacopeia-Drug Information (USP-DI); formulary is a periodically updated guide to covered generic and brand drugs and may not include all dosages/strengths. |
Imaging / Radiologymixed
| No codes listed |
Excluded service categoriesmixedNot Covered
| No codes listed |
Foreign emergency claims requirementsmixedExperimental
| Foreign emergency claims must be submitted in English or with English translation within 180 calendar days, include applicable medical records and the Member Reimbursement Medical Claim Form; reimbursement based on member benefit plan, eligibility, member cost share, and currency conversion; emergency services covered up to 90 consecutive days while traveling outside the U.S. |
LTACH ventilator threshold — mechanical ventilation requirement for LTACH consideration
LTACH ventilator thresholdMechanical ventilation for 21 consecutive days for six hours or more per day
Weaning potential requirementPatient must exhibit weaning potential without untreatable/progressive lung or neurological conditions
Ventilator management frequencyVentilator management required at least every four hours with appropriate diagnostics and assessments
LTACH respiratory thresholds — respiratory stability parameters (PEEP/FiO2/SpO2)
Respiratory stability parametersPEEP ≤10 cm H2O; FiO2 ≤60%; O2 saturation ≥90%
Hemodynamic statusPatient should be hemodynamically stable and not vasopressor dependent
Transition considerationPatient must continue to meet these criteria and not meet criteria for transition to alternate level of care
Medication balance-on-hand and refill threshold — refill prohibition until ≤15 days on hand
Refill prohibition thresholdMedication refills prohibited until member's cumulative balance-on-hand is ≤15 calendar days' supply
Operative with other limitsThis provision operates in addition to any applicable medication quantity limit or refill guidelines
ScopeApplies to prescription drug benefits as stated in the contract
Split-fill initial supply limit — 15-day supplies for first 90 days
Initial split-fill supply limitMembers limited to 15-day supplies for the first 90 calendar days when starting certain new therapies
Cost-share mechanicsMembers pay half of the 30-day cost share for each 15-day supply (i.e., half of standard 30-day cost share per 15-day fill)
Post-90-day supplyAfter 90 calendar days, members may fill 30-day supplies per standard rules
Center of Excellence travel distance threshold — 60 miles travel threshold for ancillary reimbursements
Travel distance thresholdMember required to travel more than 60 miles from residence to qualify for Center of Excellence ancillary reimbursements
Reimbursable items scopeReimbursable services include transportation, lodging, and related approved items per member transplant reimbursement guidelines
Documentation windowReceipts and arrangements must be submitted within six months of the date of service for reimbursement
Organ transplant preauthorization lead time — at least 30 calendar days to initial evaluation
Organ transplant preauthorization lead timeAt least 30 calendar days to the initial evaluation for organ transplant services
Center of Excellence requirementTransplant services require prior authorization through a Center of Excellence before transplant evaluation and related services
Submission methodsPrior authorization requests must be submitted by telephone, fax, or provider web portal as described
Clinical trial preauthorization lead time — at least 30 calendar days to receiving clinical trial services
Clinical trial preauthorization lead timeAt least 30 calendar days to receiving clinical trial services (prior authorization required)
Routine care coverage noteRoutine patient care costs in approved clinical trials are covered when services are otherwise covered under the contract
Participation requirementParticipation and facility qualifications for trials must meet stated criteria and may be subject to authorization
Elective inpatient admission authorization — at least five calendar days prior to elective admission
Elective inpatient authorization lead timeAt least five calendar days prior to an elective admission as an inpatient in a hospital, extended care or rehabilitation facility, hospice facility or residential treatment facility
Exceptions and urgent reviewsUrgent pre-service reviews follow shorter timeframes (urgent reviews within 48 hours) per prior authorization procedures
Submission methodsAuthorization requests must be submitted by telephone, fax, or provider web portal
Home health start authorization — at least five days prior to start of home health care (except post-discharge)
Home health start authorization lead timeAt least five calendar days to the start of home health care, except for members needing home health care after hospital discharge (post-discharge exception)
Prior authorization requirementHome health care services are subject to prior authorization as outlined in the policy
Covered services scopeIncludes skilled services, home health aides as part of skilled program, IV medications, therapy fees, rental of DME, and necessary supplies
Inpatient admission notification — notify within 24 hours of inpatient admission
Inpatient admission notification timeframeNotify insurer within 24 hours of any inpatient admission, including emergent inpatient admissions
Purpose of notificationNotification allows coverage and authorization review for medically necessary services and concurrent review as applicable
How to notifyPrior authorization requests and notifications must be submitted by telephone, fax, or provider web portal as specified
timeliness thresholds — claim notice within 30 days; proof of loss within 90 days; refund of unearned premium within 20 days
Claim notice timeframeNotice of claim required within 30 calendar days of the date the loss began or as soon as reasonably possible
Proof of loss timeframeWritten proof of loss must be received within 90 calendar days of the loss or as soon as reasonably possible
Refund upon cancellationUnearned premium refunded within 20 calendar days after contract cancellation
Clean claim processing times — 30 days electronic / 45 days paper; No Surprises Act claims processed within 30 days regardless of method
Clean claim electronic processing timeClean claims filed electronically processed within 30 calendar days
Clean claim paper processing timeClean claims filed on paper processed within 45 calendar days
No Surprises Act processingClaims subject to federal No Surprises Act balance billing protections are processed within 30 calendar days regardless of submission method
Key Terms and Definitions
Contract / Evidence of Coverage — definition of the contract and components
Contract componentsThis Evidence of Coverage together with the corresponding Schedule of Benefits and the enrollment application constitute the entire contract governing covered services, limitations, and exclusions
Legal effectThe document is a legal agreement under which benefits are provided and paid, subject to definitions, provisions, limitations, and exclusions
Amendments and ridersAny amendments or riders attached to this contract form part of the agreement
Guaranteed Renewable — definition and renewal exceptions
Guaranteed renewable definitionGuaranteed renewable means the plan will be renewed on the anniversary date into the subsequent year's approved product unless terminated earlier per contract terms
Renewal exceptionsWe may decline renewal for reasons including withdrawal from service area, non-payment of premium, fraud/material misrepresentation, or changes in law preventing continued offering
Premium changesPremium rates may change annually and are based on the rate table in effect on the premium due date; rates for a calendar year are guaranteed once set
Acute rehabilitation — intensity and therapy frequency definition
Acute rehabilitation intensityIntensive, multidisciplinary rehabilitation with therapies performed three or more hours per day, five to seven days per week while confined as an inpatient
Provider managementMedically managed by specially trained physicians within an inpatient hospital, rehabilitation facility, or extended care facility
ScopeCombination of therapies may include physical, occupational, and speech therapy as needed
Allowed amount — definition of allowed amount and relation to member cost sharing
Allowed amount definitionThe maximum amount the plan will pay a provider for a covered service; for network providers it is the contracted fee; subject to member cost sharing
Non-network differencesIf services are received from a non-network provider, members may be responsible for the difference between allowed amount and provider's billed amount (balance billing) unless protections apply
Relation to cost sharingAllowed amount is subject to deductible, copayment, and coinsurance per the Schedule of Benefits
Applied behavior analysis (ABA) — definition of ABA
ABA definitionApplied behavior analysis (ABA) is the design, implementation, and evaluation of environmental modifications by a board-certified behavior analyst using behavioral stimuli and measurement to produce socially significant improvement
Service componentsABA may include direct observation, measurement, and functional analysis of the relationship between environment and behavior
Authorization noteABA services are subject to prior authorization to determine medical necessity (see coverage sections)
Authorization — definition that an authorization approves medical necessity but is not a payment guarantee
Authorization definitionAuthorization (authorized) means our decision to approve medical necessity or appropriateness of care; authorizations are not a guarantee of payment
Who grants authorizationAuthorizations are decisions by Ambetter (our plan) typically involving the member's PCP or provider to approve services prior to receipt
ImplicationFailure to obtain required authorization may result in denied benefits; authorizations do not substitute for claims adjudication/payment processes
Balance billing protections — definition and relation to the No Surprises Act
Balance billing protectionsProtections under the federal No Surprises Act that prohibit non-network providers from billing members beyond applicable network cost sharing for specified covered services
Covered service examplesIncludes emergency services, certain non-emergency services at network facilities absent valid notice-and-consent, and air ambulance services
Member actionIf balance billed when protections apply, member should contact Member Services immediately as noted in the contract
Maximum out-of-pocket amount — definition and included cost-sharing elements
Maximum out-of-pocket definitionThe maximum cost sharing a member must pay in a plan year, including deductible, copayments, and coinsurance amounts shown in the Schedule of Benefits
Family calculationFamily maximum out-of-pocket equals two times the individual maximum; once an individual meets their individual max, remaining family OOP can be met by eligible expenses of any members
Effect of non-networkEligible expense determinations and non-network balance billing can affect whether amounts count toward the OOP limit
Eligible expense — definition for network and non-network providers
Eligible expense definition (network)For network providers, the eligible expense is the contracted fee the provider agreed to accept
Eligible expense (non-network)For non-network providers, eligible expense varies by law and whether balance billing protections apply; reimbursement may be determined by plan per applicable law
Impact on member liabilityWhen balance billing protections apply for non-network services, member cost sharing is calculated as if services were provided by a network provider
Experimental or investigational — definition and exceptions for trials
Experimental or investigational definitionServices lacking FDA approval or accepted evidence are considered experimental/investigational, with specific exceptions for routine care costs in Phase III/IV clinical trials and certain trial circumstances
Trial exceptionsPhase III/IV FDA clinical trials may have routine care costs covered if services are otherwise covered under the contract
Documentation basisDeterminations reference FDA approval status, authoritative compendia, and peer-reviewed clinical evidence as applicable
Hospital — institutional definition for coverage purposes
Hospital definitionAn institution operating pursuant to law that provides inpatient care, 24-hour RN nursing, organized diagnostic and treatment facilities, and has physician staff available at all times (not primarily a long-term care facility)
Inpatient distinctionServices rendered to an overnight resident patient using and being charged for room and board constitute inpatient services
ICU/standardsIntensive care unit defined per Joint Commission standards for special care units
Hospital (alternate) — additional hospital definition text
Alternate hospital definition textHospital operates primarily for reception/care of inpatients, provides 24-hour RN nursing, organized diagnostic/treatment facilities, has physician staff available, and is not primarily a long-term care facility
Usage noteUsed to determine facility eligibility for inpatient and related benefits under the contract
Inpatient — definition of inpatient services and residence
Inpatient definitionServices, supplies or treatment received by a person who is an overnight resident patient of a hospital or other facility using and being charged for room and board
Implication for coverageHospital confinement as inpatient requires that diagnosis/treatment cannot be safely provided outpatient
Medically necessary — definition of medical necessity criteria
Medically necessary definitionServices/items consistent with symptoms/diagnosis, provided per accepted medical standards, not custodial or convenience, likely to improve function, not experimental, and provided in most cost-effective setting
Hospital confinement clauseFor hospital confinement, medically necessary means diagnosis and treatment cannot be safely provided as outpatient
Scope limitsDoes not exceed needed scope, duration, or intensity of care
Network / Network provider / Network eligible expense — network definitions and implications
Network definitionNetwork is contracted providers/facilities who agree to provide services to members for agreed fees; network eligible expense includes emergency services even if by non-network provider
Network providerLicensed entities contracted with Ambetter Health to provide covered services (hospitals, physicians, pharmacies, labs, etc.)
Network eligible expense implicationDetermines allowed amount and cost-sharing calculations for covered services
Notice and consent — conditions for waiving balance-billing protections under No Surprises Act
Notice and consent definitionConditions under which a member may waive balance-billing protections per the No Surprises Act, including written notice timing (≥72 hours or ≥3 hours for services scheduled within 72 hours) and required consent elements
Exclusions from waiverNotice and consent cannot waive protections for emergency services, air ambulance, unforeseen urgent needs, situations with no network provider at facility, or certain ancillary services
Documentation requirementsMember must receive written notice in the format required by law and provide voluntary written consent; provider must furnish copy of notice and consent
Dependent eligibility / Newborn and adopted child coverage — dependent eligibility events and automatic coverage windows
Dependent eligibility eventsDependent members become eligible on event-specific dates such as date of birth, date of placement for adoption, date of marriage, or date domestic partnership established per state law
Newborn automatic coverage windowAn eligible newborn is covered from time of birth until the 31st day after birth unless insurer receives notice; additional premium required to continue beyond 31 days
Adopted child coverage windowAn adopted child placed with you is covered from date of placement until the 31st day after placement; additional premium required within 90 calendar days to continue beyond 31 days
placement — placement definition reference
Placement definitionFor adoption provisions, placement means the earlier of date you assume physical custody for adoption or date of entry of an order granting custody for adoption
Effect on coverageCoverage and premium calculations for adopted child are based on date of placement
cost sharing — definition and notes
Cost sharing definitionCost sharing means participation in health care costs via deductible, copayment, and coinsurance amounts as listed in the Schedule of Benefits
ApplicationEach claim is adjudicated separately and cost sharing for each service is applied per the Schedule of Benefits
ExamplesCopayments due at time of service, coinsurance as member share, and deductibles that must be met before benefits payable
maximum out-of-pocket — definition cross-reference
Maximum out-of-pocket cross-referenceMaximum out-of-pocket equals the total of deductible, copays, and coinsurance required in a plan year; family OOP equals two times individual maximum
Counting toward OOPEligible expenses and specific benefit limits determine whether amounts contribute toward OOP per the Schedule of Benefits
Schedule of BenefitsApplicable deductible, copayment, and coinsurance amounts are shown on the Schedule of Benefits
balance billing — definition of balance billing and member liability
Balance billing definitionBalance billing is when a non-network provider bills the member for the difference between the plan's payment and the provider's full charge
Potential effectsBalance-billed amounts may not count toward the member's annual OOP and can increase member liability unless protections apply
Member recourseIf balance billed when protections apply, contact Member Services immediately
Health Savings Account (HSA) — HSA definition and member responsibilities
Health Savings Account (HSA) definitionAn HSA is a tax-exempt custodial account owned by a member to pay for qualified medical expenses; members are solely responsible for federal eligibility and account administration
Plan roleThe Evidence of Coverage is not an HSA trustee or custodian; Ambetter/Celtic do not provide HSA custodial services or tax advice
Member responsibilitiesMembers must notify HSA custodian if coverage under HSA-compatible plan is canceled or terminated and adhere to federal HSA rules
Durable medical equipment (DME) — definition and characteristics of DME
DME definitionDurable medical equipment is equipment that can withstand repeated use, is primarily used to serve a medical purpose, is not useful in absence of illness/injury, and appropriate for home use
Rental vs purchaseDME may be rented or purchased at plan's option; purchase may be authorized when cost-effective
Included costsDelivery and installation costs are covered; repair of medical equipment is covered; related supplies covered per rental/ownership rules
Emergency ambulance transportation — definition for emergency ambulance transport
Emergency ambulance transportation definitionTransport when the member is experiencing an emergency condition to the nearest hospital that can provide appropriate services; emergency transports do not require prior authorization
Non-emergency authorizationNon-emergency ambulance transportation (air or ground) requires prior authorization
Balance billing noteUnless required by law, non-network ambulance providers may balance bill; members should refer to balance billing protections for exceptions
Orthotic device — orthotic definition
Orthotic device definitionA medically necessary device used to support, align, prevent or correct deformities, improve function or assist dysfunctional joints; casting, molding, fittings and adjustments included
Replacement frequencyOrthotic appliances may be replaced once per year when medically necessary; additional replacements allowed if medically necessary or irreparably damaged
ExamplesIncludes cervical collars, ankle foot orthosis, splints, corsets, trusses, wristlets, built-up shoes, custom shoe inserts
Prosthetic device — prosthetic definition
Prosthetic device definitionArtificial substitutes for body parts that replace or restore function; covered services include purchase, fitting, adjustments, repairs and replacements when medically necessary
Purchase preferenceProsthetic devices should be purchased rather than rented when medically necessary and cost-effective
Included costsApplicable taxes, shipping and handling are covered
LTACH — long-term acute care hospital definition and criteria
LTACH definitionLong-term acute care hospitals furnish extended medical and rehabilitative hospital-level care for clinically complex patients needing extended stays; benefits subject to prior authorization
Common medically necessary conditionsIncludes complex wound care, infectious disease requiring parenteral agents, medical complexity with multiple comorbidities, rehabilitation needs, failed weaning attempts, and ventilator support criteria
Prior authorizationLTACH benefits require prior authorization as outlined in the policy
Low-protein food products — definition and list of inherited metabolic diseases treated
Low-protein food products definitionSpecially formulated foods with less than one gram of protein per serving used under physician direction to treat specified inherited metabolic diseases (e.g., PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, urea cycle defects, tyrosinemia)
ScopeCovered when used for dietary treatment of listed inherited metabolic diseases; does not include natural low-protein foods or other excluded dietary formulas
Medical foods noteMedical foods and formulas are covered for certain outpatient nutritional therapies and for PKU/inborn errors as medically necessary
Self-injectable drugs — definition and benefit/payment implications
Self-injectable drugs definitionDrugs delivered into muscle or under the skin with a syringe and needle; patient or caregiver can administer after initial instruction
Benefit/payment implicationSelf-injectable drugs are covered under the prescription drug benefit and subject to prescription drug cost sharing
Administration noteAlthough initial medical supervision or instruction may be needed, ongoing administration is by patient/caregiver when appropriate
Formulary or Prescription Drug List — definition and update cadence
Formulary definitionA periodically updated guide to available generic and brand drugs approved by FDA and covered under the prescription drug benefit; not exhaustive and may not include all dosages/strengths
Update cadenceThe formulary is periodically reviewed and updated and may be subject to change; members should consult AmbetterHealth.com for current list
LimitationsSpecific plan designs may not cover certain products or categories regardless of appearance on the formulary
Exigent circumstances — definition for expedited reviews and exceptions
Exigent circumstances definitionWhen a member is suffering from a condition that may seriously jeopardize life, health, or ability to regain maximum function, or is undergoing a current course of treatment using a nonformulary drug
Effect on review processAn expedited exception review may be requested under exigent circumstances with decision provided within 24 hours; if granted, coverage provided for duration of exigency
Who may requestMember, member's designee, or prescribing physician may request expedited review
Split-Fill Dispensing Program — definition and cost-share mechanics for split-fill dispensing
Split-Fill Dispensing Program definitionMembers limited to 15-day supplies for the first 90 calendar days when starting certain new therapies; cost share is half of the 30-day cost share for each 15-day supply
Cost-share mechanicsMembers pay half the 30-day cost share for a 15-day supply and are responsible for the other half for subsequent 15-day fills until 90 days elapse
Post-90-day policyAfter 90 calendar days, members may fill medications in standard 30-day supplies per usual rules
Lock-In Program — definition and member notification/appeal rights
Lock-In Program definitionMembers identified for overutilization or abuse may be locked into a specific pharmacy for duration of program; members and providers will be notified and appeals rights provided
RestrictionsLocked members can obtain medications only at the specified pharmacy locations during participation
Notification methodMembers and associated providers will be notified via mail with details on duration, pharmacy, and appeals rights
Urgent care services — definition and examples
Urgent care services definitionMedically necessary services by network providers and services provided at an urgent care center including facility costs and supplies; care needed after PCP hours is considered urgent care
Access guidanceMembers encouraged to contact PCP first; network urgent care centers/walk-in clinics may be used when urgent PCP appointment unavailable
Nurse Advice Line24/7 Nurse Advice Line available for triage and guidance (1-855-604-1303)
Pre-service/prior authorization, concurrent review, and retrospective review — utilization review type definitions
Utilization review typesPre-service/prior authorization, concurrent review, and retrospective review are the utilization review types used to manage services
Prior authorization requirementSome medical and behavioral health covered services require prior authorization; network providers generally must obtain authorization before providing such services
TimeframesUrgent pre-service reviews within 48 hours; urgent concurrent within 1 calendar day; non-urgent pre-service within 5 business days; retrospective within 30 calendar days
Allowable expense — coordination of benefits term definition
Allowable expense definitionNecessary, reasonable, and customary item of expense for health care when covered under any involved plans; used in coordination of benefits determinations
Use in COBWhen Medicare is primary, Medicare's allowable expense is used when Ambetter is secondary
Relation to paymentAmbetter will not pay more than it would as primary and coordinates payments to avoid excess payment
Plan — definition for COB purposes
Plan definition (COB)Plan includes group and non-group insurance contracts and specified coverage types used in coordination of benefits; excludes accident-only, hospital indemnity, specified disease, and Medicare supplement policies
Primary plan rolePrimary plan pays first and determines benefits without regard to secondary plans; order of benefit determination rules apply for dependents and other scenarios
Primary plan — COB role definition
Primary plan role definitionA primary plan is one whose benefits are determined without considering other plans; order of benefit rules determine primary vs secondary when multiple plans exist
Order determination examplesRules include birthday rule for parents, custody/court decree rules for children, active vs retired employee rules, and other regulatory rules
Effect on AmbetterWhen Ambetter is secondary to Medicare, Medicare's allowable applies as the allowable expense
Clean claim — definition and implications for processing
Clean claim definitionA claim submitted that has no defect, impropriety or particular circumstance requiring special treatment preventing payment
Processing implicationClean claims are processed within specified timeframes (30 days electronic, 45 days paper) and requests for additional information must be made within 30 days
No Surprises Act impactClaims subject to No Surprises Act are processed within 30 days regardless of submission method
Expedited Appeal — definition and 48-hour resolution timeline
Expedited Appeal definitionAn appeal filed when a requested service would seriously jeopardize life, health, or ability to regain maximum function; resolved within 48 hours
Initiation methodsMembers may initiate expedited appeals orally via Member Services or in writing by mail or fax; provider documentation supporting urgency is required
Process exceptionStandard acknowledgement/panel requirements do not apply to expedited appeals due to 48-hour timeframe
External Review / IRO — definition and binding nature of IRO determinations
External Review / IRO definitionIndependent review by an IRO for certain adverse benefit determinations; IRO decision is final and binding on the insurer and free to the member
ScopeAvailable for determinations involving medical necessity, appropriateness, level of care, experimental/investigational status, rescissions, and surprise billing applicability
TimeframesStandard external review decision provided within 15 business days; expedited external review decisions and notifications within 72 hours
Grievance — definition and examples of non-adverse dissatisfaction
Grievance definitionAn expression of dissatisfaction other than an adverse benefit determination (e.g., customer service, provider access, or quality of care); must be filed within 180 calendar days
Filing and acknowledgementStandard grievances acknowledged within five business days and resolved in writing within 20 business days (may extend 10 business days)
Submission methodsMembers may file grievances by calling Member Services or in writing by mail or fax with supporting details and documentation
PHI — Personal Health Information definition and protections
PHI definitionPersonal Health Information (PHI) — health information protected in oral, written, and electronic forms; protected per HIPAA and Notice of Privacy Practices
Member accessMembers may request the complete Notice of Privacy Practices via Ambetter website or Member Services
Protection obligationsAmbetter follows HIPAA requirements to protect PHI and issues annual notice of practices
Auxiliary aids/services — definition and examples of language/auxiliary services
Auxiliary aids/services definitionTranslation, interpretation, and other aids and services provided at no cost to assist members with auditory or visual conditions affecting communication
Access methodTo receive translation or auxiliary services, contact Member Services at 1-877-687-1182 (TTY 1-800-743-3333)
Multilingual availabilityLanguage assistance examples include Burmese, Tagalog, Spanish, German, French, and others as noted in member materials
Processing Times, Deadlines, and Numeric Thresholds
Policy Summary
PayerCentene / Ambetter Health (Celtic Insurance Company)
PolicyEvidence of Coverage / Individual Member Contract — 2025
Policy CodePolicy AMB24-IN-C-00014
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for specified non-emergency services (submit via phone, fax, or provider web portal; urgent reviews within 48 hours).
SourceLink
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Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.