Centene Ambetter Evidence of Coverage Policy Update | OpenPayer
CurrentCentenePolicy N/A
Ambetter Individual Member Contract (Evidence of Coverage)
This document is an individual member contract (Evidence of Coverage) describing benefits, member rights/responsibilities, access to care, prior authorization requirements, and how covered services are provided by Ambetter Health (Celtic Insurance Company). It affects enrolled members and dependent members under the plan.
Policy Summary
PayerCentene
PolicyAmbetter Individual Member Contract (Evidence of Coverage)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization as required by the PRIOR AUTHORIZATION section before providing services to avoid denied benefits.
No material clinical or coverage changes in this revision.
RequiredPrior auth noted
Jan 1, 2022No Surprises Act
1-833-543-3145Member Services
31 daysNewborn coverage period
15 daysRefill threshold
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30 / 45 daysClean claim time
Coverage, Eligibility, and Benefit Rules
Coverage overview
Agreement and consideration, table of contents pointers, and major medical overview.
This document, together with the Schedule of Benefits and your enrollment application, forms the contract under which Centene (Ambetter Health) provides benefits for covered services. Benefits are subject to contract definitions, provisions, limitations, and exclusions. In consideration of your application and timely premium payment, we will provide benefits as outlined in this contract (Agreement and Consideration).
The plan provides Major Medical Expense Benefits for covered services that are medically necessary and not experimental or investigational. Essential health benefits include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care. Essential health benefits provided within this contract are not subject to lifetime or annual dollar maximums.
All covered services are subject to prior authorization where required, cost sharing (deductibles, copayments, coinsurance) and the specific limits described in your Schedule of Benefits. Providers should verify prior authorization requirements and benefit levels prior to furnishing services.
Provider network and directory
Provider network information and how members locate and verify network providers.
A Provider Directory is available online at AmbetterHealth.com via the "Find a Doctor" tool (Ambetter Health network). The directory can be filtered by specialty, ZIP code, gender, languages spoken, and whether a provider is accepting new patients; search results include provider name, address, phone, office hours, specialty, board certifications and qualifications.
Members may request a paper copy of the Provider Directory at no charge by calling Member Services. Member Services will respond to inquiries about a provider's network status within one business day.
Members may designate a network primary care physician (PCP) for each member. Members should call the PCP's office to make appointments; if assistance is needed, contact Member Services.
If services are received from a non-network provider due to inaccurate directory information or an erroneous network-status response, contact Member Services immediately. For covered services in these circumstances, members should only be responsible for network-level cost sharing and should not be balance billed by the non-network provider; see Balance Billing protections for details.
Balance billing and eligible expense criteria
Balance billing protections, eligible expense rules for network and non-network providers, and emergency services handling.
Under federal law (effective January 1, 2022) and applicable state law, non-network providers and facilities are prohibited from balance billing members for services subject to balance billing protections (No Surprises Act). Members are responsible only for the member cost share calculated as if services were received from a network provider and based on the recognized amount defined by law.
Eligible expense for covered services received from a network provider is the contracted fee with that provider.
For non-network providers where balance billing protections apply, the eligible expense is the negotiated fee, if any, mutually agreed upon by Centene and the provider; if no negotiated fee exists and absent contrary law, eligible expense and reimbursement will be determined consistent with applicable law.
Emergency services are covered without prior authorization and include evaluation and stabilization (medical screening exam and services needed to stabilize the emergency condition). Emergency services are covered both in and out of the service area, 24/7. If admitted as an inpatient following emergency care, members or providers must notify the plan within 48 hours or as soon as reasonably possible to confirm inpatient appropriateness and avoid possible financial responsibility for care later determined not medically necessary.
Newborn and adopted child coverage criteria
Coverage for newborns, adopted children, newborn charges, and federal protections for length of stay after childbirth.
Coverage for a newborn child: An eligible newborn will be covered from birth until the 31st calendar day after birth. Each type of covered service incurred by the newborn is subject to the cost sharing amounts in the Schedule of Benefits. Additional premium is required to continue coverage beyond the 31st calendar day; the premium is calculated from the child's date of birth. Coverage terminates on the 31st calendar day unless notice and any required premium are received.
Coverage for an adopted child: An eligible child placed for adoption is covered from the date of placement until the 31st calendar day after placement (unless disrupted earlier). The child is covered for injury and illness, including medically necessary care for pre-existing conditions. Additional premium is required to continue coverage beyond the 31st calendar day; premium is calculated from the date of placement. Coverage terminates on the 31st calendar day after placement unless required premium and notice are received within applicable timeframes (see dependent addition rules).
Newborn charges: Medically necessary services (including hospital services) for a covered newborn are provided immediately after birth. Each service incurred by the newborn will have separate cost sharing as listed in the Schedule of Benefits. Refer to the Dependent Member Coverage provisions for details.
Dependent addition and newborn/adoption coverage
Dependent addition rules and timing requirements for newborn and adopted children.
To add a newborn or newly placed adopted child to coverage beyond the initial 31-calendar-day period, the member must notify the plan and pay any additional premium required. For adopted children, coverage begins on the date of placement and continues for 31 calendar days; to continue coverage beyond that period, required premium and notice must be received. For adoptive placement, "placement" means the earlier of the date physical custody is assumed for adoption or the date an order granting custody for adoption is entered.
Failure to provide timely notice and payment will result in termination of the child's coverage after the 31st calendar day. Members should contact Member Services for assistance with adding a dependent and determining premium obligations.
Enrollment periods
Special and limited enrollment period rules and qualifying events.
Special enrollment: Generally, a qualified individual has 60 calendar days to report a qualifying event and may be granted a 60-calendar-day special enrollment period. If a qualified individual loses Medicaid or CHIP coverage that is minimum essential coverage, they have up to 90 calendar days after loss to enroll.
Qualifying events that may trigger special or limited enrollment include (but are not limited to): loss of minimum essential coverage, gaining a dependent through marriage, birth, adoption, placement for adoption, or court order, permanent move gaining access to new health plans, certain errors or misrepresentations by HHS or its agents, becoming a victim of domestic abuse or spousal abandonment seeking separate enrollment, or changes in eligibility for advance premium tax credits or cost-sharing reductions. Members should report qualifying events and contact Member Services for enrollment assistance.
Payment policies
Premium payment, grace periods, third-party payment rules, and underwriting adjustments for misstatements.
Premiums are due on or before their due date; the initial premium must be paid prior to the coverage effective date (extensions may be provided during Open Enrollment). If a member is not receiving a premium subsidy, monthly premiums are due in advance on the first calendar day of each month. There is a 60-calendar-day grace period for nonpayment; during the grace period the contract remains in force but claims may pend and providers will be notified of possible denied claims.
Ambetter Health reserves the right to apply rewards (e.g., My Health Pays) that convert to monetary value to unpaid premiums or related amounts owed by a member.
Third-party premium payments are generally not accepted except for specific allowable payors (e.g., Ryan White Program, Indian tribes/tribal organizations, state/federal programs, certain tax-exempt organizations, family members, certain employer HRA arrangements, qualifying private foundations). Payments from unacceptable third parties will be rejected and the member notified.
Underwriting adjustments: If a member misstates age or tobacco/nicotine use on the enrollment application, the plan may adjust premiums retroactively to the correct rate effective the original effective date (misstatement of age or tobacco/nicotine use are material to underwriting).
Underwriting adjustments
Underwriting adjustments related to tobacco/nicotine misstatements.
If tobacco or nicotine use was misstated on the enrollment application and the member's actual usage differs, Centene has the right to re-rate the contract retroactive to the original effective date to reflect correct underwriting. Members should ensure accurate enrollment information to avoid retroactive premium adjustments.
Cost-sharing
Cost-sharing definitions and rules (deductible, copayments, coinsurance, maximum out-of-pocket).
Cost sharing: Members share in the cost of health care via deductible amounts, copayments, and coinsurance, as shown in the Schedule of Benefits. Each claim is adjudicated separately for covered services and cost share applies per claim as described in the contract and Schedule of Benefits.
Deductible: The deductible is the amount of covered services that must be paid by members before certain benefits are payable. Not all covered services are subject to the deductible; copayments typically do not count toward the deductible. See the Schedule of Benefits for deductible amounts and which services are exempt.
Copayments: A copayment is a fixed dollar amount due at the time of service. Copayments are due at the time of service and do not count toward the deductible but do apply toward the maximum out-of-pocket.
Coinsurance: Coinsurance is the member's share of the cost of a service (typically a percentage). Coinsurance does not apply toward the deductible but does apply toward the maximum out-of-pocket. After a member meets the individual out-of-pocket maximum, the plan will pay 100% of allowed amounts for covered services.
Eligibility and termination
Eligibility and termination rules for subscribers and dependent members.
Subscriber termination: A member's eligibility ceases on the earlier of events such as plan non-renewal (per Discontinuance provisions), subscriber moving permanently outside the service area, fraud or intentional misrepresentation, member's death, failure to pay premiums, or effective date requested by the member (subject to notice limitations). Members should contact Member Services for questions or to report material modifications in family status.
Dependent termination: A dependent ceases to be a member at the end of the premium period in which they cease to be a dependent (e.g., due to divorce or reaching age limit). Enrolled dependent members continue coverage until the age limit listed in the definition of eligible child, except that an eligible child may remain dependent beyond the age limit if (a) not capable of self-sustaining employment due to a disability that began before the age limit, and (b) mainly dependent on the subscriber for support.
Selected covered services and limitations
Selected covered services, service-specific coverage criteria, limits, prior authorization, and exclusions across major benefit areas.
Major Medical: Covered services must be medically necessary and not experimental/investigational. Some services require prior authorization (see Prior Authorization provision). Copayments are due to network providers at time of service and all services are subject to contract conditions, exclusions, and limitations.
Acquired Brain Injury: Coverage includes a range of rehabilitative services (cognitive, neurobehavioral, neurofeedback, community reintegration, etc.) when medically necessary; custodial and long-term nursing care are not covered under this provision.
Acupuncture: Covered on an outpatient basis when provided by a network provider; see Schedule of Benefits for limits.
Ambulance (Air/Ground/Water): Emergency transport to the nearest appropriate facility is covered; non-emergency air/ground/water transport requires prior authorization. Air ambulance limits and eligible scenarios are specified; members should not be balance billed for covered ambulance services.
Code Lists, Financial Definitions, and Quick Values
Financial definitionsmixed
Allowed amount / eligible expense concepts referenced (no explicit codes in this section).
Orthotic devices (e.g., ankle-foot orthosis, custom made shoe inserts, corsets, splints, trusses, slings, wristlets, built-up shoes, devices for plagiocephaly, orthopedic shoes, standard elastic stockings); orthotics may be replaced once per year when medically necessary; exclusions include arch supports and corrective shoes unless integral to a leg brace.
Prosthetic devices (artificial substitutes for body parts), including internal cardiac devices, pacemakers, LVAD (only as bridge to transplant), custom fabricated breast prostheses (post-mastectomy) with one additional prosthesis per affected breast, wigs (one per calendar year when purchased through a network provider), cochlear implants, ostomy supplies, and related repairs/adjustments; if multiple devices meet needs, only the most cost-effective covered.
Genetic and molecular testing referencesmixed
No codes listed
inv-49: Family deductible multiplier
Family deductible multiplierFamily deductible = 2 x individual deductible (family deductible satisfied when either one member meets individual deductible or family meets family deductible)
ReferenceSee Schedule of Benefits for specific deductible amounts and application to covered services
ApplicationApplies to calendar year deductibles for family coverage
inv-50: Foot orthotics frequency
Foot orthotics frequencyOne pair of foot orthotics per year per member
Authorization, Notifications, and Appeals (Provider Responsibilities)
Prior Authorization
Emergency services authorization rule
Some medical services are covered without prior authorization when they are emergency services. Emergency services include facility costs, physician services, supplies, and prescription drugs charged by the facility. If admitted due to an emergency condition, the member or provider must notify us within 48 hours or as soon as reasonably possible so we can review whether the inpatient setting and continued days are medically necessary. Care provided once the member is stabilized is no longer considered emergency services; continuation beyond stabilization requires authorization and medical necessity. Emergency air ambulance services do not require prior authorization when the member is experiencing an emergency condition. Members should call 911 (or 988 for behavioral health emergencies) or go to the nearest emergency room for emergency conditions.
Emergency services covered both in and out of service area
Notify us within 48 hours (or as soon as reasonably possible) after emergency inpatient admission
Post-stabilization care requires authorization to be covered
Emergency air ambulance: no prior authorization required
Prior Authorization
Key Term Definitions
inv-80: Defined terms
Defined termsItalicized words in the contract have special meanings and are defined in the DEFINITIONS section
ScopeDefinitions apply throughout the contract and affect interpretation of coverage, exclusions, and member obligations
ExamplesTerms include: 'Covered service', 'Medically necessary', 'Network provider', 'Allowed amount', and others as listed in DEFINITIONS
inv-81: Contract parties
Contract parties'You' or 'your' refer to the member or dependent members; 'we', 'our', 'us' refer to Ambetter Health (Celtic Insurance Company)
Contract documentsThis document together with the Schedule of Benefits and enrollment application constitute the entire contract
Policy Summary
PayerCentene
PolicyAmbetter Individual Member Contract (Evidence of Coverage)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization as required by the PRIOR AUTHORIZATION section before providing services to avoid denied benefits.
For non-emergency ambulance and air ambulance services prior authorization is required. Covered ambulance services (ground, water, air) for emergency conditions should not result in balance billing; non-emergency transport requires prior authorization.
Newborns' and Mothers' Health Protection Act: Federal law generally may not restrict hospital length of stay to less than 48 hours after vaginal delivery or 96 hours after cesarean delivery. Providers do not need prior authorization for a length of stay not exceeding those limits; the attending provider may, after consulting with the mother, discharge earlier if appropriate.
Maximum out-of-pocket: Members must pay applicable copayments, coinsurance, and deductible amounts until they reach the individual maximum out-of-pocket in the Schedule of Benefits. The family maximum is generally two times the individual maximum. Certain benefit limits, eligible expense determinations, and non-network reductions may affect the amount payable and cost sharing.
Autism Spectrum Disorder: Coverage includes evaluation, applied behavior analysis (no annual limit for ABA services), behavior training/management, habilitation, speech/occupational/physical therapy, psychiatric care, and medications for ASD when prescribed by a physician or behavioral health practitioner. ABA and other services are subject to prior authorization for medical necessity.
Clinical Trials: Routine patient care costs for qualifying clinical trials (phases I–IV as specified) are covered when trial requirements are met; investigational item/service itself and items for research data collection are excluded.
Preventive Care and Screening: Preventive services are covered per ACA, USPSTF, ACIP, and HRSA guidelines. Network preventive services are covered without member cost share. Preventive vs diagnostic billing determines applicable cost share.
Diabetic Care: Medically necessary services and supplies for treatment of diabetes are covered, including self-management equipment, orthotics, diabetic shoes, and education; state/federal limits on insulin cost sharing apply.
Dialysis: Medically necessary acute and chronic dialysis services (in-facility and home) are covered; home dialysis equipment and supplies covered after training and per authorization; limits and DME rules apply.
Orthotics & Prosthetics: Initial purchase, repair, adjustments, and replacement may be covered when medically necessary. Reimbursement may be limited to a standard item if comfort/luxury features exceed medical necessity. Specific orthotic and prosthetic items are listed; some items and circumstances (lost/stolen, misuse) are excluded.
Disposable Medical Supplies & DME: Disposable supplies with a primary medical purpose are covered subject to quantity limits and applicable member cost sharing. Durable medical equipment may be rented or purchased at plan discretion; many DME items are covered but are subject to prior authorization and reasonable quantity limits.
Family Planning & Contraception: Preventive family planning services and full range of FDA-identified contraceptives are covered without cost sharing when provided by a network provider, in accordance with HRSA guidance and applicable law. Services integral to furnishing contraceptives (e.g., anesthesia for sterilization) are included.
Fertility Preservation: Medically necessary standard fertility preservation for iatrogenic infertility due to cancer treatment is covered; prior authorization may be required.
Habilitation/Rehabilitation/Extended Care: Coverage for habilitation and rehabilitation services is available when medically necessary; benefits are limited to specified facility and professional services; prior authorization may apply; care ceases to be rehabilitation when maximum therapeutic benefit reached or goals not met.
Home Health Care: Medically necessary network home health services are covered (home health aide, private-duty RN outpatient, therapy services, IV meds, hemodialysis at discretion, DME rental/purchase); prior authorization may apply; respite/custodial/educational care excluded.
Hospice Care: Hospice inpatient, home and outpatient care for terminally ill members is covered when medically necessary under a hospice program; respite, counseling, palliative care, bereavement counseling included; prior authorization may apply; exclusions/limitations described.
Hospital Benefits: Inpatient and outpatient hospital services are covered (room and board, ICU, operating room use, routine inpatient drugs/supplies). See Schedule of Benefits for limits.
Emergency Services: Emergency care covered 24/7 both in and out of service area; emergency services subject to balance billing protections; follow-up care is not emergency care; continuation of care beyond stabilization requires authorization to be covered.
LTACH: Long-term acute care hospital benefits are subject to authorization and medical necessity; common conditions and criteria for LTACH level of care are described.
Infertility: Coverage limited to medically necessary diagnostic tests and treatment of underlying medical conditions causing infertility; assisted reproductive technologies (IVF, GIFT, ZIFT, artificial insemination) are excluded unless otherwise stated.
Lymphedema: Lymphedema treatment is covered when prescribed by a licensed physician or provided at an authorized facility; coverage includes multilayer compression bandaging and gradient compression garments.
Mammography: Screening and diagnostic mammography, tomosynthesis, MRI, ultrasound and pathology aligned with USPSTF guidelines are covered when prescribed by a licensed practitioner; see Preventive Care Guide for details.
Maternity: Inpatient stays minimum 48 hours for vaginal delivery and 96 hours for cesarean delivery are covered; prior authorization is not required for delivery or for a length of stay within federal limits. Maternity-related outpatient and inpatient services, complications of pregnancy, prenatal testing, education and postpartum care are covered; some services may require authorization.
Medical & Surgical Benefits: Surgical services, pre- and post-surgical testing, genetic and molecular testing, biomarker testing, and medically necessary reconstructive and corrective procedures are covered when medically necessary; refer to Schedule of Benefits for limits.
Medical Dental Services: Medically necessary dental services (anesthesia, hospital charges for dental care, oral surgery for cleft lip/palate, TMJ, orthognathic surgery, etc.) are covered when criteria are met and for eligible members (age and disability criteria apply).
Medical Foods & Low-Protein Foods: Outpatient medical foods and formulas for TPN, elemental formulas, and dietary formula for PKU and certain inborn errors of metabolism are covered when medically necessary. Low-protein foods for certain inherited metabolic diseases are covered; exclusions for other dietary supplements apply.
Pediatric Vision & Adult Vision: Vision benefits for children under 19 and adults 19+ are provided per the plan provisions; covered items include routine exams, frames, lenses, contact lenses (in lieu of glasses), and certain lens options. LASIK and some services are excluded. Refer to Schedule of Benefits for limits.
Prescription Drug Benefits & Self-Injectables: Covered per formulary; off-label drugs are covered if supported by compendia or clinical evidence; self-injectable drugs covered under prescription benefit; medication refill and balance-on-hand rules and extended days' supply limits apply.
Medication Refill and Extended Days' Supply Rules: Refills are restricted when member has >15 days' supply on hand. Extended-day supply restrictions and exclusions for certain drug categories apply; specialty drugs generally limited to 30-day supply retail.
Non-Formulary / Exception Process & Step Therapy: Members/providers may request standard (72-hour decision) or expedited (24-hour decision) exceptions for non-formulary drugs. External review of exception denials is available with specified response timelines. Protocol exceptions to step therapy may be granted for clinical contraindications, prior intolerance or ineffectiveness, or other clinically appropriate reasons; clinical documentation may be requested.
Preventive Care: Preventive services covered per ACA/USPSTF/ACIP/HRSA; network preventive services covered without member cost share. Preventive care guides are available online and updated annually; HSA-compatible plan rules apply for benefits exceeding federal preventive requirements.
Radiology & Diagnostic Testing: Medically necessary diagnostic imaging and testing are covered; prior authorization may be required. Billing can include technical and professional components and non-network providers should not balance bill when balance billing protections apply.
Second Medical Opinion: Members are entitled to a second opinion for recommended surgery, serious illness/injury, or unsatisfactory response to treatment. If choosing a network provider, only applicable cost sharing applies. A second opinion from a non-network provider requires prior authorization to be an eligible expense; otherwise the member may be liable and subject to balance billing.
Sleep Studies: Sleep studies (in-home or facility) are covered when medically necessary; prior authorization may be required.
Transplant Benefits: Transplants are covered when the member is accepted as a transplant candidate and pre-authorized through a Center of Excellence or authorized facility; pre-transplant evaluation, harvesting, LVAD as bridge, transplant surgery, post-transplant follow-up, and donor expenses are covered as specified. Travel and lodging reimbursement for Centers of Excellence may be available when travel exceeds 60 miles, subject to limits and documentation. Many transplant-related exclusions and limits apply (including non-authorized facilities, research transplants, non-covered ancillary expenses).
Urgent Care: Urgent care services by network providers and walk-in clinics are covered; care needed after PCP hours is considered urgent care. Members should consult their PCP or the 24/7 Nurse Advice Line (1-833-543-3145) for guidance.
Wellness Programs & Member Perks: Centene may offer wellness and preventive programs (My Health Pays, Ambetter Perks) and other optional services at no extra cost; rewards may be converted to monetary value and applied to unpaid premiums. Programs vary by market and are not insurance.
Prior authorizationAll DME and supplies are subject to prior authorization as outlined in this contract
ExceptionsAdditional pairs may be allowed if medically necessary and authorized
inv-51: Wig limit
Wig limitOne wig per calendar year when purchased through a network provider
Prosthetics sectionWigs listed as a prosthetic-related item; non-network wigs may be excluded
DocumentationPurchase through network provider required for annual coverage limit
inv-52: Medication refill threshold
Medication refill thresholdRefills prohibited until member's cumulative balance-on-hand is equal to or fewer than a 15‑day supply
Operates with other limitsThis operates in addition to any applicable medication quantity limits or refill guidelines
EnforcementApplies to all prescription refill processing under the pharmacy benefit
inv-53: maximum supply limits
Maximum supply limitsStandard retail: 30‑day supply; select maintenance drugs via mail order or participating pharmacies: up to 90‑day supply; specialty and select categories limited to 30 days
Cost sharing noteOnly the 90‑day supply may be subject to discounted cost sharing for eligible mail orders
ExclusionsCertain categories (specialty, institutional, infertility drugs, others listed) remain limited to 30 days or excluded
inv-54: refill prohibition threshold
Refill prohibition thresholdNo refills allowed if member has more than a 15‑day supply on hand; refills prohibited until balance-on-hand ≤ 15 days' supply
Overlap with extended days' supply rulesApplies even where extended days' supply options exist; see formulary and Schedule of Benefits for exceptions
Compound drugsCompound drugs excluded unless at least one ingredient is FDA‑approved; refill rules apply accordingly
inv-55: Elective inpatient prior auth lead time
Elective inpatient prior auth lead timeAt least five calendar days prior to an elective inpatient admission (hospital, extended care, rehabilitation, hospice, or residential treatment)
Provider responsibilityNetwork providers must obtain authorization prior to providing the elective service to avoid denial
ExceptionsEmergency admissions are not subject to pre‑authorization but require notification within stated timeframes
inv-56: Inpatient admission notification
Inpatient admission notificationNotify us within 48 hours or as soon as reasonably possible for emergency admissions; for any inpatient admission notification must be within 24 hours per prior authorization rules
PurposeNotification allows plan to review medical necessity and authorize continued inpatient care to avoid potential member financial responsibility
Non‑contracted hospitalsIf admitted to a non‑contracted hospital, notify within two calendar days so insurer can review and authorize medically necessary services
inv-57: age limit for dependent child
Age limit for dependent childCoverage for a dependent child terminates on the 31st day of December of the year the child turns 26
Continuation exceptionsDependent may continue beyond age limit if primarily dependent and disabled prior to limit, per contract provisions
Effective dateRefer to enrollment and termination provisions for timing and notice requirements
Prior authorization definition
Prior authorization is a decision to approve specialty or other medically necessary care for a member by the member's PCP or provider group prior to the member receiving the services. It is required for certain medical and behavioral health services as indicated in the Schedule of Benefits. Failure to obtain required prior authorization may result in denial of benefits and, for non-network providers, potential balance billing to the member. Network providers cannot bill the member for services they fail to obtain authorization for when required.
Definition: decision to approve specialty or medically necessary care prior to services
Required when indicated on the Schedule of Benefits
Consequences: denial of benefits and potential balance billing if authorization not obtained
Prior Authorization
Inpatient prior-notification/authorization for ongoing hospitalizations
If a member is an inpatient on the contract effective date, notify us within two calendar days of the effective date so we can review and authorize medically necessary services. For all inpatient admissions, including emergent inpatient admissions, prior authorization requests must be received within 24 hours of the admission. Concurrent review applies during ongoing inpatient stays and we will notify you of the number of days considered medically necessary once contacted.
Notify us within two calendar days of effective date if member is inpatient on effective date
Prior authorization for inpatient admissions: within 24 hours of any inpatient admission (including emergent admissions)
Concurrent review used to review ongoing hospitalizations
Prior Authorization
Prior authorization for non-emergency services
Non-emergency services obtained outside the service area (for example when traveling) may require prior authorization if received from an Ambetter provider outside the member's home state or other non-network providers. Non-emergency air and ground ambulance transportation requires prior authorization. Non-emergency services provided by non-network providers generally require prior authorization in advance; otherwise the member may be responsible for charges.
Non-emergency out-of-area Ambetter providers may require prior authorization
Non-emergency air ambulance services require prior authorization
Non-network non-emergency services require prior authorization to avoid member liability
Prior Authorization
Prior authorization rules for ambulance and clinical trials
Air ambulance services for emergency conditions do not require prior authorization. Non-emergency air ambulance and other non-emergency ambulance transport require prior authorization. Transportation between facilities or to/from home may require authorization when ordered or authorized by us. Members should not be balance billed for covered air ambulance services when balance billing protections apply.
Emergency air ambulance: no prior authorization
Non-emergency air ambulance: prior authorization required
Covered air ambulance examples: transport to nearest appropriate hospital, neonatal special care unit, transfers when authorized
Prior Authorization
LTACH and Hospice prior auth
LTACH and hospice services are subject to prior authorization. LTACH admissions require authorization and are considered when medically necessary for complex, extended hospital-level care (examples include complex wound care, intensive infectious disease management, multiple active co-morbidities requiring monitoring). Hospice inpatient, home and outpatient care benefits are subject to prior authorization and coverage limits in the Schedule of Benefits.
LTACH benefits subject to authorization; common medically necessary conditions listed in policy
Hospice benefits (inpatient, home, outpatient) subject to prior authorization and Schedule limits
Respite care limitations and coverage applied toward deductible/maximums as specified
Prior Authorization
Formulary Exception Requests
Formulary exception requests (standard and expedited) and external exception review are available when a drug is not covered or when a step therapy/protocol exception is needed. Standard exception requests will receive a coverage determination within 72 hours; expedited requests within 24 hours when exigent circumstances exist. If internal exception requests are denied, the member or prescriber may request an independent external exception review: we will notify the requester of the external review decision within statutory timeframes and, if granted, coverage will be provided for the duration specified.
Standard exception: determination within 72 hours
Expedited exception: determination within 24 hours for exigent circumstances
External exception review timelines: 3 business days for standard original request denials; 1 business day for expedited denials
Note
Lock-In Program Notification
Members identified for the Lock-In Program may be restricted to a specific pharmacy to decrease overutilization or abuse. Members and associated providers will be notified by mail and provided information on duration, designated pharmacy, and appeals rights.
Lock-in notifications sent by mail to member and providers
Notification includes duration, locked pharmacy, and appeals rights
Prior Authorization
Prior Authorization requirements and timeframes
Prior authorization request timing and decision timeframes: pre-service (non-urgent) requests must be decided within five business days of receipt; urgent pre-service reviews within 48 hours; urgent concurrent reviews (when received at least 24 hours prior to expiration) within 24 hours, otherwise within 72 hours; concurrent urgent reviews within one calendar day as applicable. Required submission timeframes include at least five calendar days prior to elective inpatient admissions, at least 30 calendar days prior for initial organ transplant evaluations and clinical trial services, within 24 hours of any inpatient admission, and at least five calendar days prior to start of home health care (except post-discharge home health). Timeframes may be extended if additional information is needed in accordance with law.
Non-urgent pre-service decision: within 5 business days
Urgent pre-service decision: within 48 hours
Urgent concurrent: within 24 hours (if received ≥24 hours before expiration) or within 72 hours otherwise
Concurrent review and inpatient admission notification: within 24 hours of inpatient admission
Submission lead times: elective inpatient admissions ≥5 calendar days; organ transplant initial evaluation ≥30 calendar days; clinical trial services ≥30 calendar days; home health start ≥5 calendar days (except post-discharge)
Note
Utilization review types & OB/GYN access
Utilization review includes pre-service (prior authorization), concurrent (reviews during care such as inpatient stays), and retrospective reviews (after services have been provided). Members do not need prior authorization to access in-network OB/GYN practitioners for obstetrical or gynecological care; however, those practitioners may still need to obtain prior authorization for specific services or follow pre-approved treatment plans. For services requiring authorization, network providers must obtain authorization prior to providing the service or supply, per the Schedule of Benefits.
Members have direct access to in-network OB/GYNs without prior authorization for the practitioner visit
OB/GYNs may need to comply with authorization procedures for certain services
Prior Authorization
Non-network provider prior authorization
Services from non-network providers generally require prior authorization when covered services cannot be obtained from a network provider within a reasonable distance. If prior authorization for non-network services is not obtained, the member may be responsible for all charges. Balance billing protections may apply to certain covered services from non-network providers; when they apply, non-network providers should not bill the member beyond applicable cost-sharing.
Prior authorization required before receiving services from a non-network provider when network providers are not reasonably available
Failure to obtain authorization for non-network services may result in full member liability
Balance billing protections apply in states/situations specified elsewhere (e.g., emergency and certain radiology services)
Denial Risk
Appeals and External Review Procedures
If prior authorization or other authorizations are denied, members have appeal rights under the Grievance and Appeal Procedures. An appeal is a request to review an adverse benefit determination and must be filed within 180 calendar days of the determination. Appeals may be submitted in writing or orally and will be acknowledged within five business days. Standard appeals are decided within 30 calendar days (with a possible 14-calendar-day extension with consent); expedited appeals (serious jeopardy to life/health/ability to regain maximum function) are resolved as quickly as the member's health requires but not more than 48 hours. If dissatisfied with the internal appeal outcome, members may request an external review by an Independent Review Organization for qualifying adverse determinations. External review decisions are binding and the member will not pay costs associated with the IRO.
Time to file appeal: within 180 calendar days of adverse determination
Standard appeal decision timeframe: within 30 calendar days (±14-day extension with consent)
Expedited appeal decision timeframe: within 48 hours
External review available for qualifying adverse determinations; binding decision and no cost to member
Denial Risk
Rescission and repayment for fraud
A member's coverage may be rescinded retroactively for intentional and material misrepresentation in the enrollment application if the misrepresentation was written, signed, provided to the member, and was intentional and material to issuance of coverage. During the first two years of coverage, if a member commits fraud, misrepresentation, or knowingly provides false eligibility or claims information, the payer has the right to demand repayment of all benefits paid during the period the member was covered.
Rescission conditions: written signed misrepresentation that is intentional and material
Repayment: within first two years, insurer may demand repayment for benefits paid if member committed fraud or knowingly provided false information
Legal entityAmbetter Health operates under Celtic Insurance Company and both may be referred to as the plan
inv-82: Adverse benefit determination
Adverse benefit determinationA decision that denies, reduces, or fails to provide or pay in whole or in part for a covered service, finds a service not medically necessary, investigational, an eligibility denial, a rescission, or a determination that balance billing protections do not apply
AppealsRefer to the APPEAL AND GRIEVANCE PROCEDURES section for rights to appeal adverse benefit determinations
ScopeIncludes prospective and retrospective review determinations and incorrectly calculated member cost share when balance billing protections apply
inv-83: Allowed amount
Allowed amountThe maximum amount the plan will pay a provider for a covered service; for network providers this is the contracted fee; subject to member cost sharing
Non-network implicationsWhen services are from a non-network provider, member may be balance billed for amounts above allowed amount unless balance billing protections apply
Relation to eligible expenseAllowed amount ties to eligible expense definitions elsewhere in the contract for coordination and COB
inv-84: Balance billing
Balance billingA non-network provider billing the member for the difference between the provider's charge and the eligible expense (allowed amount); network providers do not balance bill beyond member cost sharing
Member actionContact Member Services immediately if balance billed to determine applicability of balance billing protections
Impact on OOPAmounts paid due to balance billing may not count toward annual maximum out-of-pocket unless protections apply
inv-85: Balance billing protections
Balance billing protectionsNo Surprises Act protections limit member liability for emergency services, certain non-emergency services at network facilities, and air ambulance services; member pays only applicable cost share calculated as if services were from a network provider
Notice & consent conditionsMember may waive protections only if non-network provider gives required written notice and good faith estimate, timing requirements (72 hours normally; 3 hours if scheduled within 72 hours), and obtains voluntary written consent
DocumentationProvider must provide copies of notice/consent and comply with additional statutory conditions for post‑stabilization services
inv-86: Authorization
Authorization (definition)Our decision to approve the medical necessity or appropriateness of care for a member by the member's PCP or provider; authorization is not a guarantee of payment
TypesIncludes pre-service/prior authorization, concurrent (utilization) review, and retrospective review
Provider requirementNetwork providers must obtain authorization prior to providing services that require it; failure may result in denial
inv-87: Authorized representative
Authorized representativeAn individual authorized in writing, legally authorized to provide substituted consent, or a family member/treating professional when the member is unable, to represent a covered person in appeals or external review
UseCan be designated to pursue internal appeals or request external review on behalf of the member
DocumentationWritten consent or evidence of legal authorization required for representation
inv-88: Emergency services / condition
Emergency services / conditionServices to evaluate and stabilize acute symptoms that a prudent layperson would consider an emergency; emergency services covered without prior authorization
Post-stabilizationContinuation of care beyond stabilization is not emergency care and requires authorization to be covered; notify plan within 48 hours to avoid financial responsibility
Cost shareMember pays cost share as listed in Schedule of Benefits; balance billing protections apply for emergency services
inv-89: Home health care agency
Home health care agencyAn agency operating pursuant to law that provides home health care under RN supervision, maintains daily medical records, and provides a planned program of physician‑directed treatment; Medicare‑approved agencies deemed acceptable
ServicesCovers skilled home health services and related supplies when physician‑directed and medically necessary
Prior authorizationPrior authorization requirements apply to home health services per contract
inv-90: Hospice / Hospice care program
Hospice / Hospice care programCoordinated interdisciplinary program prescribed and supervised by a provider for terminally ill members in inpatient or home settings; certified, state‑licensed hospice programs used
Covered servicesIncludes inpatient room/board (up to semiprivate), palliative care, counseling, bereavement counseling, and respite care subject to prior authorization and Schedule of Benefits
Rate limitsHospice inpatient room and board not to exceed most common semi‑private room rate of associated hospital or nursing home
inv-91: Hospital
HospitalAn institution operating pursuant to law for inpatient reception, care and treatment with 24‑hour RN nursing, physician availability at all times, organized diagnostic/treatment facilities, and not primarily a long‑term care facility
Inpatient definitionServices received as an overnight resident patient charged for room and board constitute inpatient care
ExclusionsUnits used primarily for custodial or rehabilitation care may not be considered hospital confinement for contract purposes
inv-92: Medically necessary
Medically necessaryCovered services/items consistent with diagnosis/symptoms, conforming to generally accepted medical practice, not custodial, likely to improve function, not experimental, provided in the most cost‑effective setting and not excessive in scope/duration/intensity
Hospital confinementFor inpatient stays, must be medically necessary because care cannot safely be provided outpatient
Effect on coverageCharges for services determined not medically necessary are not eligible expenses
inv-93: Network / Network provider
Network / Network providerA group of contracted providers and facilities (hospitals, physicians, pharmacies, labs, etc.) that agreed to provide services for an agreed fee; members receive most care via the network
Network eligible expenseEligible expense for services by a network provider; includes emergency services even if by non‑network provider
DirectoryProvider directory available online and via Member Services for locating network providers
inv-94: Notice and consent (No Surprises Act)
Notice and consent (No Surprises Act)Conditions to waive balance billing protections: non‑network provider must provide required written notice with good faith estimate, timing requirements (72 hours normally; 3 hours if scheduled within 72 hours), obtain voluntary written consent acknowledging potential balance billing and non‑applicability to deductibles/OOP, and provide copies to member
ScopeApplies to non‑emergency services at network facilities and certain post‑stabilization scenarios when all statutory conditions are met
Member protectionsWhen protections apply, member pays only applicable cost share calculated as if services from a network provider
inv-95: Dependent member eligibility
Dependent member eligibilityDependent members become eligible on the later of subscriber's effective date, date of marriage, birth of eligible newborn, date an adopted child is placed or custody assumed, foster placement date, or domestic partnership establishment per law
Enrollment mechanicsRefer to dependent addition provisions and Schedule of Benefits for required notices and premium payments
Temporary newborn coverageNewborns covered automatically for 31 days pending enrollment notification and premium payment to continue coverage
inv-96: Newborn and adopted child temporary coverage
Newborn and adopted child temporary coverageAn eligible newborn or adopted child is covered from time of birth or placement until the 31st calendar day after birth/placement; additional premium required to continue coverage beyond 31 days
Adoption placement timingFor adopted children, coverage begins at date of placement and 'placement' defined as earlier of physical custody assumption or court order granting custody
Premium timing for adoptionTo continue coverage beyond 31 days for an adopted child, required premium must be received within 90 calendar days of placement
inv-97: Episode of care
Episode of careServices provided by a facility or provider to treat a condition or illness; multiple claims for the same episode are adjudicated separately as received
Claims processingEach claim processed according to contract cost share and Schedule of Benefits for that service
RebatesAmbetter may offer rebates for evidenced-based selections demonstrating higher quality and lower cost
inv-98: Placement
Placement (adoption)Defined as the earlier of (1) date physical custody assumed for adoption or (2) date of entry of order granting custody for adoption
Coverage startCoverage for adopted child begins on date of placement
Continuation requirementsAdditional premium required to continue coverage beyond 31 days; see adoption provisions for timing
inv-99: Coinsurance / Maximum Out-of-Pocket
Coinsurance / Maximum Out-of-PocketCoinsurance is member's share of service cost; coinsurance and copayments count toward maximum out‑of‑pocket but not toward deductible; after individual OOP met plan pays 100%
Family OOP relationFamily maximum out‑of‑pocket equals two times the individual maximum; once one member meets individual OOP, remaining family OOP can be met by combination of other members' eligible expenses
Schedule of BenefitsSpecific deductible, copayment, coinsurance and OOP amounts are shown in the Schedule of Benefits
inv-100: Balance billing / Non-network liability
Balance billing / Non-network liabilityNon‑network providers may bill the member for amounts above the plan's allowed amount (balance billing); these amounts may not count toward the member's deductible or maximum out‑of‑pocket unless protections apply
Hospital-based providersHospital-based non‑network providers may balance bill even at network hospitals unless member has valid notice and consent under No Surprises Act
Member recourseIf balance billed, member should contact Member Services immediately to determine applicability of protections
inv-101: Clinical Trial Coverage
Clinical Trial CoverageRoutine patient care costs for approved phase I‑IV clinical trials for cancer or other life‑threatening conditions are covered when trial meets listed sponsor/approval requirements; participation is subject to prior authorization
Covered itemsIncludes FDA‑approved drugs, medically necessary services to administer trial drug/device, and routine items provided to qualified individuals (excluding investigational items and data‑collection only services)
Facility/provider requirementsTrial must be conducted at qualified facilities with appropriate expertise; certain phase I/II trials must be NIH/NCI sanctioned
inv-102: Ambulance Services
Ambulance ServicesEmergency air, ground and water ambulance transport to the nearest appropriate facility are covered; emergency transport does not require prior authorization; non‑emergency transport requires prior authorization
Air ambulance specificsEmergency air ambulance not subject to prior authorization; non‑emergency air ambulance requires prior authorization; members should not be balance billed for covered ambulance services
ExclusionsAmbulance services covered by local government, comfort/convenience transports, and non‑ambulance transport modes are excluded
inv-103: Iatrogenic infertility
Iatrogenic infertilityInfertility caused by medical intervention (including reactions from prescribed drugs or medical/surgical procedures provided for cancer treatment)
Fertility preservationMedically necessary fertility preservation services are covered when cancer treatment may cause iatrogenic infertility; prior authorization may be required
ApplicabilityCoverage limited to medically necessary diagnostic/treatment services related to iatrogenic infertility as described in contract
inv-104: Minimum hospital length of stay
Minimum hospital length of stayFederal Newborns' and Mothers Health Protection Act: minimum 48 hours for vaginal delivery and 96 hours for cesarean; attending provider may discharge earlier with patient agreement; no plan authorization required for stays within statutory minima
Provider notificationProviders may elect earlier discharge after consulting with mother; plan cannot require authorization for stays ≤ statutory minimums
ScopeApplies to mother and newborn inpatient stays related to childbirth
inv-105: Medical foods / Low-protein food products
Medical foods / Low‑protein food productsCovered when medically necessary: outpatient TPN, elemental formulas for malabsorption, and dietary formulas for PKU and listed inborn errors of metabolism; low‑protein foods for specified inherited metabolic diseases covered under criteria
Covered conditionsIncludes PKU, MSUD, MMA, IVA, propionic acidemia, glutaric acidemia, urea cycle defects, tyrosinemia, and others listed in contract
ExclusionsGeneral dietary formulas, oral nutritional supplements, prepared foods/meals and formulas for access problems are excluded
inv-106: formulary or prescription drug list
Formulary (prescription drug list)The formulary is a guide to covered generic and brand drugs approved by the FDA and covered under the prescription benefit; it is periodically reviewed and may change
TieringPreferred brand drugs listed on Tier 2; generic drugs are first‑line where available; specific plan designs may exclude categories
AccessCurrent formulary and pharmacy program details available at AmbetterHealth.com or via Member Services
inv-107: Over-the-Counter (OTC) prescriptions
Over‑the‑Counter (OTC) prescriptionsOTC medications are covered when ordered by a physician and marked 'OTC' on the formulary
RequirementsPrescription order must meet legal requirements and the OTC product must be listed on the formulary to be covered
ReferenceSee formulary and Schedule of Benefits for covered OTC items and cost sharing
inv-108: Technical vs professional components
Technical vs professional componentsRadiology/imaging services may generate two bills: technical component (procedure) and professional component (interpretation); each subject to applicable cost sharing
Prior authorizationMedically necessary radiology and imaging may require prior authorization per Schedule of Benefits
Balance billing protectionsWhen balance billing protections apply, non‑network providers should not bill the member beyond applicable cost share for radiology/imaging services
Pre‑service/prior authorization, concurrent review, retrospective reviewUtilization review types include pre‑service/prior authorization, concurrent (ongoing) review, and retrospective review; members may access certain OB/GYN services without prior authorization though specific services may still require it
Lead times and timeframesTimeframes for authorization requests and decision turnaround specified in PRIOR AUTHORIZATION section; failure to obtain required authorization may result in denial
How to obtainAuthorization requests accepted by phone, fax or provider web portal; contact information on member ID card
inv-110: Allowable expense
Allowable expenseThe necessary, reasonable, and customary item of expense for health care when covered under any involved plan; used in Coordination of Benefits determinations
Application to COBWhen Medicare is primary, Medicare's allowable expense is used if Ambetter is secondary; allowable expense informs benefit reductions when plan is secondary
Definition sourcesCOB follows NAIC guidelines and applicable federal/state regulations
inv-111: Plan (COB) definition
Plan (COB) definition'Plan' means a form of coverage written on an expense‑incurred basis with which coordination is allowed (includes group/non‑group contracts, Medicare where permitted, auto medical payments, etc.); excludes Medicaid/state plans and certain limited benefit products
Included/ExcludedExamples of included plans: group and non‑group insurance, closed panel plans, automobile medical payments; excluded: hospital indemnity, accident‑only, specified disease coverage
Use in COB orderDefinition guides Order of Benefit Determination rules for primary vs secondary payment
inv-112: Primary plan / Secondary plan
Primary plan / Secondary planPrimary plan's benefits are determined without regard to other plans; secondary plan applies after primary and may reduce benefits so total does not exceed allowable expense
Order rulesOrder of benefit determination rules (e.g., birthday rule, active vs retired employee, custody decrees) determine primary/secondary status
Effect when secondaryWhen secondary, Ambetter will reduce benefits so total payments do not exceed Ambetter's maximum allowable benefit and may limit to Medicare allowable when applicable
inv-113: Plan
Plan'Plan' is used throughout COB and coordination provisions to denote coverage types subject to coordination rules; see COB definitions for included/excluded plan types
RelevanceDetermines interactions with other coverages when member insured under multiple plans
ReferenceSee Coordination of Benefits section for application and examples
inv-114: Primary plan
Primary planA plan whose benefits are determined without considering other plans (e.g., active employee plan may be primary); a plan is primary if it has no order of benefits rules or rules differ from regulation
Determination examplesRules include employee vs dependent status, birthday rule for parents, active vs retired employee rules
ImplicationPrimary plan pays first; secondary plan may offset remaining eligible expenses
inv-115: Secondary plan
Secondary planAny plan that is not primary; when multiple secondary plans exist, order of benefit determination rules decide payment order among them
Benefit reductionSecondary plans may reduce payments so combined payments do not exceed allowable expense
Coordination mechanicsSee COB section for tie‑breaking rules (birthday rule, custody, active/retired status, length of coverage)
inv-116: External Review
External ReviewAn external review by an Independent Review Organization (IRO) is available when internal appeals of adverse benefit determinations involving medical judgment are unsatisfactory; external review decision is binding on the plan
EligibilityAvailable for disputes involving medical necessity, appropriateness, level of care, investigational status, surprise billing applicability, and rescissions
ProcessFiling an external review will not affect ongoing health care services and the member will not pay IRO costs
inv-117: Expedited Appeal
Expedited AppealAn appeal process for requests where a requested service would seriously jeopardize life, health, or ability to regain maximum function; resolved within 48 hours
InitiationMay be initiated orally via Member Services or in writing; provider documentation supporting urgency required
Decision deliveryAll necessary information and decision will be communicated by telephone, fax, or other expeditious method
inv-118: Rescission
RescissionRetroactive voiding of coverage when intentional, material misrepresentation exists in a written enrollment application signed by the member and provided to the member; rescission has retroactive effect
ConditionsRescission may be applied only if (1) misrepresented fact is in signed written application; (2) copy of application furnished to member; and (3) misrepresentation was intentional and material
ConsequencesCoverage is voided and claims denied if coverage rescinded for fraud
inv-119: Non-Waiver
Non-WaiverFailure by either party to enforce contract terms does not constitute a waiver of rights; past non‑enforcement does not waive future rights
EffectPreserves plan's and member's rights despite previous leniency or inaction
ReferenceSee GENERAL PROVISIONS for application of Non‑Waiver clause
inv-120: Rescind/Rescission
Rescind/RescissionSee Rescissions: coverage may be retroactively voided for intentional, material misrepresentation in signed enrollment application; rescission means coverage never in effect
RequirementsA copy of the signed enrollment application must have been furnished to the member for rescission to apply
TimeframeRescission and related procedures described in GENERAL PROVISIONS section
inv-121: Repayment for Fraud
Repayment for FraudWithin the first two years of coverage, the plan may demand repayment of benefits if a member committed fraud, misrepresentation, or knowingly provided false eligibility or claims information
ScopeRepayment obligation applies to benefits provided during the time the member was covered under the contract
EnforcementPlan may seek reimbursement and take recovery actions consistent with terms of contract
inv-122: PHI
PHIPersonal Health Information (PHI) includes all oral, written, and electronic member health information protected under HIPAA; plan follows HIPAA and issues an annual Notice of Privacy Practices
Member rightsMembers receive information on how PHI is used, disclosed, and how to access their information; full Notice available upon request
ProtectionsPolicies and procedures in place to protect PHI; inquiries directed to plan privacy resources
inv-123: Language Assistance
Language AssistanceMembers who do not speak or understand the local language have the right to an interpreter at no cost; directed to the plan's language assistance web resource
AccessLanguage assistance information available at AmbetterHealth.com/language-assistance.html
Support modalitiesInterpreter services and TTY (711) available as indicated elsewhere in contract and Member Services contact information