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Ambetter Quick Reference Guide

Quick Reference Guide General InformationProvider and Member Services Phone: 1- 877-687-1180 or TTY/TDD 1- 877-941-9231 After Hours Phone: 1- 877-687-1180 or TTY/TDD 1- 877-941-9231 Website Website services include verifying eligibility, benefits, cost shares, submit prior authorizations, submission of claims, claim status and many more functions. Medical ManagementPrior Authorizations Providers may submit authorizations in 3 ways: Web Portal at : 1- : 1- 877-687-1180 Medical Admissions Fax Notification of Admissions: 1- 855-339-5150 Fax Clinical Information: 1- 866-517-7226 Claims Submissions and Claims PaymentProviders may submit claims in 3 ways: Web Portal found at ID , Resubmission, Corrected or Reconsiderations: Ambetter from Peach State PO Box 5010 Farmington, MO 63640-5010 Timely Filing: 180 days from the date of service or primary payment (when Ambetter is secondary) Claim Disputes - (Form loc)

2. EDI- Payor ID 68069 3. Paper. Initial, Resubmission, Corrected or Reconsiderations: Ambetter from Peach State PO Box 5010 Farmington, MO 63640-5010 . Timely Filing: 180 days from the date of service or primary payment (when Ambetter is secondary) Claim Disputes - (Form located on website) Ambetter from Peach State PO Box 5000

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2021 Prescription Drug List Effective January 1, 2021 . Formulary Introduction FORMULARY . The Ambetter from Peach State Health Plan Formulary, or Preferred Drug List, is a guide to available brand and ... Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit.

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SPECIALTY MEDICATION PRIOR AUTHORIZATION FORM Complete this form and send information to Peach State Health Plan, Pharmacy Department fax at 1-866-374-1579 For questions, please call 800-514-0083 option 2 ACARIA Ship to: Patient Other . OR Dispense from Office, Hospital, or Outpatient Center Stock PATIENT INFORMATION . Patient Name: Address:

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corrected claim, Request for Reconsideration, or Claim Dispute) will cause an upfront rejection. If the original claim submitted requires a correction, please submit the corrected claim following the “Corrected Claim” process in the Provider Manual. Please do not include this form with a corrected claim. Level of dispute (please check):

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