Provider Resources
Please contact your local Provider Engagement Administrator with questions. You can find your Provider Engagement Administrator by selecting the county of the primary office for your organization.
Ambetter provides the tools and support you need to deliver the best quality of care.
About Our Plans
Ambetter offers Marketplace insurance plans with different coverage, benefit options and premium levels. We expanded our plans in 2023 to help members find more coverage options. Learn more below about the options, including the new Select, Value and Virtual plans.
Ambetter Gold/Silver/Bronze Plans
- No referrals required.
- Most plans offer optional adult vision and dental coverage.
- Available in all Ambetter counties.
- This is our biggest network of healthcare providers.
Ambetter Select Plans
Ambetter Select features in-person care from a smaller network of providers.
- Referrals are not required.
- Vision and dental buy ups are not available within this plan.
- Available only in Broward and Miami-Dade counties.
Ambetter Value features in-person care from a smaller provider network. Members must select a PCP from a designated provider group.
- A referral from a member’s PCP is needed for care beyond their PCP’s scope, such as seeing a specialist.
- Referrals are not required for OB/GYN, mental health/substance abuse disorder, urgent care or emergent care.
- Members can only see PCPs within their assigned PCP group. Members must formally change their PCP group in the Member Portal or by calling member services before visiting a PCP group other than their assigned PCP group.
- Value is ONLY available in Broward, Clay, Duval, Hillsborough, Lake, Miami-Dade, Orange, Osceola, Palm Beach, Pasco and Seminole counties.
Ambetter Virtual Plans
Ambetter Virtual Access offers members a virtual primary care experience from a broad provider network. Teladoc is the exclusive virtual PCP group partnered with Ambetter from Sunshine Health.
- A referral from a member’s PCP is needed for care beyond their PCP’s scope, such as seeing a specialist. Referrals are not required for OB/GYN, mental health/substance abuse disorder, urgent care or emergent care.
- Members can visit a brick-and-mortar PCP but will be subject to applicable cost-sharing. Members will still need referrals from their brick-and-mortar PCP for care beyond their PCP's scope.
- Vision and dental buy ups are not available within this plan.
- In order to see a brick-and-mortar PCP, members must formally change their PCP to a brick-and-mortar PCP in the Member Portal or by calling member services before visiting a PCP other than their assigned Teladoc PCP.
Call Provider Services For Help
If you need help, call Provider Services at 1-877-687-1169 (Relay Florida 1-800-955-8770) Monday through Friday from 8 a.m. to 8 p.m. Eastern. Stay up to date on Ambetter from Sunshine Health provider notices by reviewing and bookmarking Provider News.
Provider Toolkit
We believe that delivering quality care doesn’t have to be complicated. So, to make working with us easier, we developed the Ambetter Provider Toolkit. It’s designed to provide you with valuable education and materials to simplify your administrative responsibilities—so you can focus on providing care.
- Provider Quick Reference Guide
- Prior Authorization Guide
- Electronic Funds Transfer (EFT) Features
- Secure Web Portal Features
- Ambetter Plan Offerings
- FAQs
Provider Forms
Training
Reference Materials
- 2024 Provider and Billing Manual (PDF)
- 2023 Provider and Billing Manual (PDF)
- Quick Reference Guide (PDF)
- ICD-10 Information
- Payspan (PDF)
- Secure Portal (PDF)
- Secure Provider Website Registration (PDF)
- Telemedicine
- Referral and Authorization Information
- Interpreter Request Form (PDF)
Medical Management
- Pre-Auth Needed?
- Prior Authorization Guide (PDF)
- Inpatient Prior Authorization Form (PDF)
- Outpatient Prior Authorization Form (PDF)
- Grievance and Appeals
- Prior Authorization Request Form for Non-Specialty Drugs (PDF)
- Prior Authorization Request Form for Specialty Medication (PDF)
- Notification of Pregnancy Form (PDF)
- Risk Adjustment Coding Guidelines
- Non-Formulary And Step Therapy Exception Request Form (PDF)
- Supplemental Outpatient Authorization Form (PDF)
Behavioral Health
- Discharge Consultation Form (PDF)
- SMART Goals Fact Sheet (PDF)
- OTR Tip Sheet (PDF)
Claims and Claims Payment
- Claim Dispute Form (PDF)
- No Surprises Act Open Negotiation Form (PDF)
Standards for Appointment Scheduling
Quality
- Quality Improvement (QI)
- Child and Adolescent Well Care Visits (WCV) (PDF)
- Practice Guidelines (PDF)
- Appropriate Treatment for Upper Respiratory Infection (URI) (PDF)
- Appropriate Testing for Pharyngitis (CWP) (PDF)
- Use of Imaging Studies for Low Back Pain (PDF)
- Pediatric HEDIS Measures (PDF)
- Providing Quality Care
Fraud, Waste, and Abuse
Language Access
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© Copyright 2024 Celtic Insurance Company. All rights reserved.
Ambetter from Sunshine Health includes EPO products that are underwritten by Celtic Insurance Company, and HMO products that are underwritten by Sunshine State Health Plan, Inc., which are Qualified Health Plan issuers in the Health Insurance Marketplace. This is a solicitation for insurance. © 2024 Sunshine State Health Plan, Inc. All rights reserved.
