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Provider Manuals and Forms | Ambetter from Coordinated Care
Provider Resources
Ambetter provides the tools and support you need to deliver the best quality of care.
Reference Materials
- 2023 Provider & Billing Manual (PDF)
- 2022 Provider & Billing Manual (PDF)
- 2021 Provider and Billing Manual (PDF)
- Quick Reference Guide (PDF)
- Prior Authorization Guide (PDF)
- New Century Health FAQ (PDF)
- Secure Portal (PDF)
- Payspan (PDF)
- ICD-10 Information
- My Health Pays Provider Educational Flyer (PDF)
- Waiting Room Quick Guide Card (PDF)
- Provider Update Tools
Medical Management
- Pre-Auth Needed?
- Inpatient Prior Authorization Fax Form (PDF)
- Outpatient Prior Authorization Fax Form (PDF)
- Grievance and Appeals
- Durable Medical Equipment (DME) Form (PDF)
- Breast Pump Request Form (PDF)
- Sterilization Consent Form (PDF)
- Biopharmacy/Buy-bill Prior Authorization Form (PDF)
Behavioral Health
- Electroconvulsive Therapy (ECT) Authorization Request Form (PDF)
- OTR Completion Tip Sheet (PDF)
- Psychological or Neuropsych Testing Authorization Request Form (PDF)
- Applied Behavioral Analysis Prior Authorization Request Form (PDF)
- Outpatient/ Inpatient Behavioral Health Service Authorization Request Form (PDF)
Vision
Ophthalmology Services
Claims and Claim Payment
- Request for Out of Network Payment Evaluation (PDF)
- Claims and Payment Decision Tree (PDF)
- Claims Trend Form (PDF)
- Provider Claims FAQ (PDF)
Quality Improvement
- Practice Guidelines (PDF)
- Quality Improvement (QI)
- Member Notification of Pregnancy (PDF)
- Member Notification of Pregnancy (PDF) (Spanish)
Reconsideration Resources
- Reconsideration Grid (PDF)
- Change in Condition (PDF)
- Claim Reconsideration and Dispute Form (PDF)
- Re-Review Request Form (PDF)