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Reference Materials

• 2022 Provider & Billing Manual (PDF)
  
• 2020 Provider & Billing Manual (PDF)
• 2021 Provider & Billing Manual (PDF)
• ICD-10 Information
• W-9 Fax Cover Sheet (PDF)
• Ambetter Provider Toolkit
• Provider Training (PDF)
• 2022 Provider Training (PDF)
  

Medical Management

• Pre-Auth Needed?
• 2021 Inpatient Prior Authorization Fax Form (PDF)
• 2021 Outpatient Prior Authorization Fax Form (PDF)
• Grievance and Appeals
• Biopharmacy Outpatient Prior Authorization Form (J-code products) (PDF)

Behavioral Health

• Discharge Consultation Documentation Fax Form (PDF)
• Inpatient Electroconvulsive Therapy (ECT) Request Form (PDF)
• Outpatient Electroconvulsive Therapy (ECT) Request Form (PDF)
• Outpatient Treatment Request Form (PDF)
• Psychological or Neuropsych Testing Inpatient Authorization Request Form (PDF)
• OTR Completion Tip Sheet (PDF)
• 2021 Inpatient Prior Authorization Fax Form (PDF)
• 2021 Outpatient Prior Authorization Fax Form (PDF)
• Change of Provider Request Form (PDF)
• Transcranial Magnetic Stimulation Services Prior Authorization Checklist (PDF)
• Psychological and Neuropsychological Testing Checklist (PDF)

High Tech Imaging

Ambetter from Superior HealthPlan has selected National Imaging Associates, Inc. (NIA) to provide radiology network management services. NIA manages the prior authorizations for non-emergent, advanced, outpatient imaging services rendered to Ambetter members. 

• NIA: High Tech Imaging QRG for Rendering Facilities (PDF)
• NIA: High Tech Imaging QRG for Ordering Physicians (PDF)

Claims and Claim Payment

• Claim Dispute Form (PDF)
• Billing and Coding

Quality

• Disease Management Program Guide (Ambetter from Superior HealthPlan and Vida Health) (PDF)
  
• Practice Guidelines (PDF)
• Quality Improvement (QI)