Frequently Asked Questions - Providers/CA - Ambetter

To enroll, you will need to "Opt In". Do this by completing the Participating Provider Enrollment Form, which can be accessed by going to the Forms section of the website. Once the form is completed, fax your form back to (470) 514-3697.

Visit our website, www.ActivHealthCare.com for extensive information on claims processing. It is essential for Provider Staff to review and understand the Provider Staff Training that is available on our website.

There are a few training presentations, with Provider Staff Training being the most important. Almost every question asked of us can quickly be answered and almost every mistake made by a CA can easily be avoided by using resources available at www.ActivHealthCare.com.

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

    1. Handwrite "Corrected Claims" at the top of the CMS1500.
    2. Put a 7 in box 22 under Resubmission Code and the original claim number in box 22 under Original Ref No. These numbers cannot be written, they must be printed on the form.
    3. Send the form to ActivHealthCare so we can attach a copy of the original Explanation of Payment to the form and send it to Peach State Health Plan.
    OR, you can submit the correction electronically as an 837P. Refer to the Peach State Health Plan document memo for more instructions.

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:

    1. Provider Tax ID # - This would be the Activ Tax ID #. (The only other time you may use it.)
    2. Control/Claim Number - This would be the Peach State Health Plan (Ambetter) claim number. Within the next week, ActivHealthCare will begin placing the Ambetter claim number on your Remittance Advice. it will be labeled PSHP Clm# and will display on the right-hand side. Until then, you will need to contact ActivHealthCare for that number.

If you have any questions on the process, please do not hesitate to contact ActivHealthCare at (770) 455-0040.

Claim Status can be tracked through the ActivHealthCare Provider Portal.

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.

The improper use of modifier 59 will probably result in the denial of a claim. You may need to file an appeal with medical records in order for the claim to be reconsidered. For example, do not use a modifier 59 when submitting for CPT code 98943. It is not required. Claims submitted with the modifier have been bundled by PSHP with the 98941 code and no additional benefits were allowed.

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

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:

    1. Recommendation from a trusted source;
    2. Low cost for our network Providers and us;
    3. Technical knowledge and ability to meet our needs; and,
    4. Providers can use Office Ally for almost all claims.

Office Ally did custom programming for ActivHealthCare, which allows claims to reach the insurance payer the same day it reaches us. Over the past several years, Office Ally has modified that programming to account for NPI verification which reduces claim rejections by payers. Last month, Office Ally programmed the Taxonomy Code to meet the Peach State Health Plan requirements.

If you are using any clearinghouse other than Office Ally, we are unable to accept your claims electronically. Other clearinghouses will not be able to run your claim through the special programming done by Office Ally and required by ActivHealthCare. They must be submitted on paper to us, which is much slower.

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.

    • If you submit claims on paper, be sure to review the training presentations to avoid unnecessary delays.
    • If you use Office Ally, the format example in the "How do I submit claims?" FAQ for the correct Peach State Health Plan (Ambetter or Allwell" formatting.
    • If you use a billing service, be sure they are properly trained. Most of the claim problems we see originate with billing services not knowing how to work with 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

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:

    AHC01 Peach State Health Plan (Ambetter)
    EDI Payer ID 68069
    P.O. Box 5010
    Farmington, MO 63640-5010

IMPORTANT BILLING INFORMATION - Taxonomy Code - Claims must be submitted with the Provider Taxonomy Code in box 24J. Please make sure it is loaded in your software. The code for Chiropractor is 111N00000X. Claims will be rejected if the Taxonomy Code is not included. Additional instructions and training presentations can be found on our website, www.ActivHealthCare.com, under Network Resources.

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. Once you verify coverage on one or two patients, it will become easy.