Providers/CA - Ambetter

How do I verify coverage?

Benefits can be verified either by calling the number on the insurance ID card or by using Availity.com. We have tested Availity and it works. The deductible and copays are the main variables. All other benefits will be the same. Below are two examples of insurance ID cards. On the top card, there is a $5 co-pay for Specialist (Chiropractors). The deductible will not apply on exams, adjustments or modalities. It may apply on X-rays. On the bottom card, the deductible applies to everything. Notice the wording difference on the card.

How do I submit claims?

Claims should be submitted through Office Ally, as stated in our EDI training at https://activhealthcare.com/network-resources/training/edi-references, with the following format:

For Ambetter, it would be as follows:

Why join through ActivHealthCare?

There are several reasons to join through ActivHealthCare, even if you already have a direct contract:

    1. The Activ fee schedule is higher
    2. Activ will be a voice and advocate for our members
    3. If you are enrolled through Activ, we can help if you have any issues
    4. Simplify your credentialing by only credentialing with Activ

Where can I find Ambetter information?

For additional Information on Ambetter, please visit their website:
https://ambetter.pshpgeorgia.com/provider-resources.html.

The Ambetter website offers easy access to Ambetter specific information, including:

    • Provider Manual
    • Prior Authorization Guidelines
    • Prior Authorization tool - very easy to use

Do I have to use Office Ally to submit my claims?

No, but if you use a clearinghouse other than Office Ally for your ActivHealthCare claims, you will need to submit paper claims to ActivHealthCare. Otherwise, the claims may be processed as out of network and denied.
Our website training at www.ActivHealthCare.com thoroughly covers how to format the address. If you have questions, call (770) 455-0040.

Why does ActivHealthCare use and recommend Office Ally for Electronic Billing?

There are many options for submitting claims electronically. ActivHealthCare researched several clearinghouses before deciding to use Office Ally. We decided on Office Ally for four reasons:

How do I use modifiers when submitting claims?

Peach State Health Plan follows CMS guidelines with respect to modifiers. Providers are expected to use modifiers appropriately. The Provider Manual and Billing Manual, which is available on the Ambetter website under Provider Resources, will give additional information. It can be accessed through the following link: https://ambetter.pshpgeorgia.com/provider-resources.html.

How do I check claim status?

Claim Status can be tracked through the ActivHealthCare Provider Portal.

How do I file an appeal with Ambetter?

If you wish to submit an appeal, you will need to follow Ambetter procedures. In order to file an appeal with Ambetter, a provider must complete a Provider Request for Reconsideration and Claim Dispute Form which can be obtained from the Ambetter website.

There are two items on the form which need to be explained:

How do I file a corrected claim?

Ambetter has a specific process for filing a corrected claims, which must be followed. Please click here for that process. There are three steps:

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